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'^feb'; ■'■'■••:■ #&!'•#.'■■■:■■ ■■ •''■^■A^iLv;*1 ■,y. % j* Ji ft CLINICAL LECTURES ji/yty // ON THE PRINCIPLES AND PRACTICE OF MEDICINE. i t BY JOHN HUGHES BENNETT, M.D., F.R.S.E., PROFESSOR OF THE INSTITUTES OF MEDICINE, AND SENIOR PROFESSOR OF CLINICAL MEDICINE IN THE UNIVERSITY OF EDINBURGH ; Formerly Lecturer on the Practice of Physic, Physician to the Fever Hospital, Director of the Poli-Clinic at the Koyal Dispensary, and Pathologist to the Eoyal Infirmary, Edin- burgh; Honorary Member and Emeritus President of the Eoyal Medical Society of Edin- burgh ; Member and Corresponding Member of various other Scientific and Med- ical Societies in Edinburgh, St. Andrews, Philadelphia, New York, Paris, Brussels, Vienna, Berlin, St. Petersburgh, Jena, Stockholm, Athens, Buda-Pesth, Copenhagen, Amsterdam, etc. FIFTH AMERICAN, From the EoTirth London Edition. Jititfr Jfi&e ||nnbreb anb &Jjirfg-scferr Illustrations an Wioob. LIBRAV:\ SU&GEON GENERAL'S OFf'JCE WILLIAM WOOD & (DOMPANY, \1Lqj1)> 61 WALKER STREET. ' ' ^ 1867. \n:b B4T5c 196.7 /til PREFACE. This work having been some time out of print, a fourth edition is now published, every part of which has received numerous ad- ditions, while some portions of it are altogether new. In Sec- tion II. I have introduced an account of the molecular and cell theories of organisation, and re-written descriptions of the gen- eral laws of nutrition and of innervation in health and disease, of inflammation, and of tuberculosis. In a note appended to the general treatment of morbid growths, I have inserted a let- ter from M. Yelpeau, in which that distinguished surgeon has, from numerous cases in his practice, demonstrated the correct- ness of the opinion I long ago formed, on pathological grounds, viz., that true cancer may be permanently extirpated with the knife. The facts he has recorded ought to put an end to further discussion on the subject. In Section III. I have introduced new considerations oil the subject of General Therapeutics, and have referred, under dis- tinct heads, to the natural progress of disease; the knowledge derived from an improved diagnosis and pathology; the fallacy of the change of type theory; an inquiry into our present means of treatment; and the proposition that physiology and pathology constitute the true foundations for medical practice. Eegarding these subjects, which constitute important principles of our science, I shall be satisfied if their perusal should induce my readers to reflect on the uncertainty of our art, and stimu- VI PEEFACE. late some of them to renewed investigations as to the exact value of remedies in the treatment of disease. In Sections IV. V. and VI. several new subjects, and many valuable cases, have been introduced, which it is hoped will render the account given of the diseases of the nervous, diges- tive, and circulatory systems, more useful to the medical prac- titioner. In Section VII. I have tabulated every case of acute Pneu- monia treated by me in the Eoyal Infirmary of Edinburgh since the year 1848, in order to satisfy my medical brethren that the restorative (not stimulating) treatment of the disease is in every way well worthy of their confidence. The facts shown by that table also will, I trust, serve to correct some prevailing errors, and establish a few new truths. In Sections VIII. IX. and X. are many additional wood illustrations and new cases; some of the latter, illustrative of albuminuria, with increased secretion, from waxy degeneration of the kidney, are deserving attention. I trust to be excused fop having still further defended my claim to the discovery of Leucocythemia. The subject of Diabetes has been extended by cases taken with great care, and a laborious trial of sugar as a remedy in that disease recorded. Certain views concerning the diagnosis and etiology of Typhus and Typhoid Fevers have been re-investigated. A very careful trial of the wet sheet in Scarlatina is detailed, and a singular new fact in the history of mercurial poisoning illustrated. These, and numerous other additions, which it is calculated have increased the work to the extent of 300 pages, I have, by curtailments, condensations, the employment of a-closer type, and a slight enlargement of the page, been enabled to effect without adding to the bulk of the volume. I have again to express my obligations to numerous friends for assistance rendered to me in various ways, and especially to PREFACE. vii Dr. Angus Macdonald, House Physician to the Eoyal Infirmary, for valuable aid in correcting the proof-sheets. Notwithstand- ing the extra pains bestowed upon it, I am still deeply sensible of the many imperfections with which this book is chargeable, and for which I once more solicit the kind indulgence of my medical brethren. It is with no small gratification, however, that I have seen the modifications which I ventured to intro- duce into the principles and practice of medicine gradually adopted by medical practitioners in this and other countries; and the good results which have everywhere followed may, I trust, now be regarded as satisfactory proof that such modifica- tions are not merely temporary changes, but permanent im- provements in the practice of the art. J. HUGHES BENNETT. Edinburgh, April, 1865. CONTENTS. List op Illustrations .... Introduction . . . The relation of the science to the art of medicine Mode of conducting the clinical course The political state of the medical profession The social state of the medical profession The present state of practical medicine SECTION I. EXAMINATION OF THE PATIENT Arrangement of symptoms, etc. Inspection of the dead body . Relative position of internal organs Inspection ...... Inspection of the general posture of the countenance of the chest of the abdomen Palpation ...... Increased or diminished sensibility of parts Altered form, size, density, and elasticity Alterations of movement Mensuration ..... Percussion ...... Of the different sounds produced by percussion Of the sense of resistance produced by percussion General rules to be followed in the practice of mediate percussion Special rules to be followed in percussing particular organs . in percussing the lungs . in percussing the heart in percussing the liver in percussing the spleen in percussing the stomach and intestines in percussing the kidneys in percussing the bladder Auscultation . . . . . . General rules to be followed in the practice of auscultation . Special rules to be followed during auscultation of the pulmonary organs . . /* . . • Of the sounds produced by the pulmonary organs in health and in disease ........ X CONTENTS. PAGE Special rules to be followed during auscultation of the circulatory organs . . . .... 70 Of the sounds produced by the circulatory organs in health and disease ..... . VI Auscultation of the abdomen ..... 73 Auscultation of the large vessels 74 Use of the Microscope ..... 75 Description of the microscope 11 Mensuration and demonstration 83 How to observe with a microscope 85 Principal Applications op the Microscope to Diagnosis . 81 Saliva ..... 88 Milk . . . ' . 89 The blood ..... 91 Pus ..... 93 Sputum ..... 94 Vomited matters .... 97 Faeces ..... 99 Uterine and vaginal discharges 100 Mucus ..... 102 Dropsical fluids .... 103 Urine ...... 103 Cutaneous eruptions and ulcers 107 Use of Chemical Tests .... 110 To detect albumen in the urine 110 To detect bile in the urine 110 To detect bile acids in the urine 111 To detect leucin and tyrozin in the urine 111 To detect sugar in the urine 111 To detect chlorides in the urine 112 SECTION II. PRINCIPLES OF MEDICINE 114 Molecular and Cell Theories op Organisation On the General Laws of Nutrition in Health and Disease Function of nutrition ..... Of the General Laws of Innervation in Health and Disease General anatomy and physiology of the nervous system General pathology of the nervous system Inflammation ...... Tuberculosis . . ... Morbid Growths op Texture—their General Pathology and ment ....... Classification ...... Fibrous growths .... Fatty growths ..... Cystic growths ..... Glandular growths .... Epithelial growths . . . Vascular growths .... Cartilaginous growths . . * . Osseous growths .... Cancerous growths .... Treat 115 124 124 137 138 148 155 179 185 187 188 196 199 206 210 216 220 225 229 CONTENTS. XI General pathology of morbid growths General treatment of morbid growths Morbid Degenerations op Texture Albuminous degeneration Fatty degeneration Pigmentary degeneration Mineral degeneration . Concretions . Albuminous concretions Fatty concretions Pigmentary concretions Mineral concretions Urinary concretions Prostatic concretions . Hairy concretions Vegetable" fibrous concretions Amyloid and amylaceous concretions 233 242 245 246 252 262 269 272 273 273 274 275 275 278 279 280 282 SECTION III. GENERAL THERAPEUTICS 284 The Influence which the Mind exerts over the Body The Natural Progress op Disease .... The Knowledge derived prom an improved Diagnosis and Pathology Fallacy of the Change of Type Theory .... On the diminished Employment of Blood-Letting and Antiphlogistic Rem edies in the Treatment of Acute Inflammations Proposition 1.—That little reliance can be placed on the experience of those who, like Cullen and Gregory, were unacquainted with the nature of, and the mode of detecting, internal inflammations Proposition 2.—That inflammation is the same now as it has ever been, and that the analogy sought to be established between it and the varying types of fevers is fallacious .... Proposition 3.—That the principles on which blood-letting and anti- phlogistic remedies have hitherto been practised are opposed to a sound pathology ....... Proposition 4.—That an inflammation once established cannot be cut short, and that the object of judicious medical treatment is to con- duct it to a favorable termination . Proposition 5.—That all positive knowledge of the experience of the past, as well as the more exact observation of the present day, alike establish the truth of the preceding principles as guides for the future' . An Inquiry into our Present Means of Treatment Dietetica ...... Hygienica ...... Materia mediea ..... Action of medicines on the ultimate elements of the tissues on the nervous system on the respiratory system on the circulatory system on the digestive system . on the genito-urinary system on the integumentary system 284 295 297 299 302 303 305 306 313 315 320 320, 323 331 336 337 339 339 341 342 343 xii CONTENTS. General theory of the action of remedies Physiology and Pathology the true Foundations for Medical Practice ........ PACE 344 347 SECTION IV. DISEASES OF THE NERVOUS SYSTEM . . 352 On the Pathology op Cerebral and Spinal Softenings, and on the Necessity of employing the Microscope to ascertain their Nature . 353 Acute Hydrocephalus—Cases I. to III. ..... 360 Pathology and treatment . . . . . .364 Cerebral Meningitis, Acute—Cases IV. to VI. . . .. . 367 Pathology and treatment . . . . . .370 Chronic—Cases VII. and VIII. . . .373 Cerebritis, Acute—Cases IX. and X. . . . . .376 Chronic—Cases XI. to XIV. ..... 380 Pathology and treatment . . . . . .387 Cerebral Disease from Obstruction of Arteries—Cases XV. to XVII. . 390 Pathology ........ 396 Cerebral Hemorrhage—Cases XVIII. to XXIX. . . . 400 Pathology and treatment . . . . . .416 Cancer of the Brain—Case XXX. ...... 421 Dropsy op the Brain—Case XXXI. ..... 424 Structural Diseases of the Spinal Cord—Cases XXXII. to XL. . . 427 Acute spinal meningitis ..... 427 Acute myelitis ....... 428 Paraplegia and chronic myelitis—Cases XXXIV. to XXXIX. . 430 Facial neuralgia, from cancerous disease of the cranium—Case XL. . 441 Functional Disorders op the Nervous System—Case XLI. . . 445 Classification of functional nervous disorders . . . 447 Pathology of functional nervous disorders .... 449 Treatment of functional nervous disorders .... 453 Delirium tremens—Cases XLII. to XLV. .... 455 Poisoning by opium—Cases XLVI. and XLVII. . . . 458 Poisoning by hemlock—Case XL VIII. .... 460 Poisoning by lead—Case XLIX. ..... 464 SECTION V. DISEASES OF THE DIGESTIVE SYSTEM . Diseases of the Mouth, Pharynx, and (Esophagus—Cases L. to LTV. Functional Disorders of the Stomach—Cases LV. to LVIII. j - . General pathology and treatment of dyspepsia Vomiting of sarcinse—LVIII. .... Organic Diseases of the Stomach ..... Chronic ulcer of the stomach—Cases LX. and LXI. Chronic ulcer of the stomach, with perforation—Cases LXII. and LXIII...... Pathology and treatment . . * . Cancer of stomach—Cases LXIV. and LXV. Poisoning by oxalic acid—Case LXVI. sulphuric acid—Case LXVII. corrosive sublimate—Case LXVIII. 466 466 472 475 479 481 481 483 488 489 495 496 496 CONTENTS. xm Diseases op the Liver Acute congestion—Case LXIX Acute jaundice—Case LXX Abscess—Case LXXI. Jaundice—Case LXX1I. Jaundice from cancer compressing the ducts—Cases LXXIII. and LXXIV. . • • Enlargement of the liver—Case LXXV. Fatty enlargement—Case LXXVI. __ . Cirrhosis—Cases LXXVII. and LXXVIII. Cancer of the liver—Case LXXIX. Hydatid cyst of the liver—Case LXXX. Diseases op the Intestines .... Diarrhoea—Cases LXXXI. and LXXXII. Constipation ..... Dysentery—Cases LXXXIII. and LXXXLV. . Chronic dysentery—Case LXXXV. Pathology and treatment of diarrhoea and dysentery Obstruction of large intestine from cancer—Case LXXXVI. Strangulation of small intestine from inguinal hernia—Case LXXXVII. Intestinal Worms—Cases LXXXVIII. to XCI Peritonitis—Cases XCII. to XCVI. PAGE 497 497 498 501 504 508 510' 511 514 518 522 524 524 525 526 527 530 534 535 542 545 SECTION VI. DISEASES OF* THE CIRCULATORY SYSTEM. 557 Pericarditis—Cases XCVII. to CII. Pathology and treatment .... Valvular Diseases of the Heart—Cases CHI. to CXV. Enlarged foramen ovale—Case CXVI. Pathology of valvular and organic diseases of the heart . Treatment of valvular and organic diseases of the heart Functional Disorders of the Heart Aneurism—Cases CXVII. to CXXVI. General diagnosis of thoracic aneurisms Physical phenomena of abdominal aneurisms Pathology and treatment of aneurisms Diseases op Veins and Lymphatics Phlebitis of the left iliac vein—Case CXXVII. Angio-leucitis—Case CXXVLU. 559 570 575 592 594 599 600 601 630 630 633 634 634 635 SECTION VII. DISEASES OF THE RESPIRATORY SYSTEM 637 Laryngitis—Cases CXXIX. to CXXXIII. Treatment by topical applications Diagnosis of laryngitis Pertussis—Case CXXXTV. 638 689 647 649 xiv CONTENTS. Bronchitis—Cases CXXXV. to CXXXVIII. Pathology and treatment ..... On injections into the bronchi in pulmonary diseases . Pleuritis—Cases CXXXIX. to CXLVI. .... Pathology, diagnosis and treatment of pleuritis Empyema—Case CXLIV. ..... Pneumonia—Cases CXLVII. to CLVII. .... On the diagnostic value of the absence of chlorides from the urine in pneumonia—Case CLIII. ..... The pathology of acute pneumonia .... Treatment of acute pneumonia .... Tabular view of 129 cases of acute pneumonia Chronic pneumonia and gangrene of the lung—Cases CLIV. to CLVII....... . Phthisis Pulmonalis—Cases CLVIII. to CLXII. On the natural progress of phthisis j.uhr.onalis—the tendency to ulcer- ation—the modes of arrestment «... Pathology and general treatment i_ _ \;3 pulmonalis Special treatment of phthisis pulmonale Cancer of the Lung—Case CLXIII. .... Carbonaceous Lungs—Cases CLXIV. to CLXV. Pathology and treatment . . . PAGE 651 655 658 660 664 671 678 686 689 692 697 713 722 733 741 749 754 756 758 SECTION VIII. DISEASES OF THE GENITO-URINARY SYSTEM 161 Ovarian Dropsy—Cases CLXVI. to CLXIX. Pathology of ovarian dropsy . Treatment of ovarian dropsy . Nephritis and Pyelitis—Cases CLXX. and CLXXI. Desquamative nephritis—Cases CLXXII. to CLXXIV. Suppurative nephritis—Case CLXXV. Scrofulous nephritis—Case CLXXVI. Calculous nephritis—Case CLXXVII. Chronic pyelitis—Case CLXXVIII. . Pathology of cystic kidney Persistent Albuminuria, or Bright's Disease—Cases CXCI. ...... Albuminuria with excessive amount of urine and waxy CLXXXVII. to CXC. Pathology of Bright's disease . Diagnosis of Bright's disease . Treatment of Bright's disease . CLXXIX. to disease—Cases 763 775 780 782 785 791 793 795 797 799 801 811 819 823 825 SECTION IX. DISEASES OF THE INTEGUMENTARY SYSTEM 827 Classification op Skin Diseases ...... 828 Diagnosis of Skin Diseases ....... 831 Porrigo ... .... 835 CONTENTS. XV The Treatment of Skin Diseases Dermatozoa ..... Acarus scabiei Entozoon folliculorum . Dermatophyta Favus—Cases CXCH. to CXCVI. '. History of favus as a vegetable parasite Mode of development and symptoms of favus Causes ..... Pathology .... Treatment PAGE 836 842 842 845 847 847 850 850 853 855 862 SECTION X. DISEASES OF THE BLOOD Leucocythemia—Cases CXCIX. to CCII. Pathology and treatment Discovery of leucocythemia Chlorosis and Anaemia—Case CCIII. Ichorh^mia or (so-called) Pyemia—Case CCIV. Pathology .... Glycoh*2emia—Cases CCV. to CCXIII. Pathology and treatment Continued Fever .... Febricula—Cases CCXIV. to CCXVII. Relapsing fever—Case CCXVIII. Typhoid fever treated by quinine—Cases CCXIX. to CCXXI. Typhus fever treated by quinine—Cases CCXXII. to CCXXVI. Typhus fever treated without quinine—Cases CCXXVII. to CCXXXII........ Diagnosis of continued fevers ..... Morbid anatomy of the Edinburgh fever during the winter 1847-8 Pathology and etiology of continued fever Typhoid succeeded by typhus fever—Case CCXXXIII Typhoid fever—CCXXXIV. ...... Table of typhoid and typhus fevers, 1862-63—Cases CCXXXV. to CCL...... Propagation of fever .... Treatment of continued fever . Iniantile Remittent Fever—Can it be separated from Acute Hydro cephalus ?—Case CCLI. Intermittent Fever—CCLII. Pathology and treatment Eruptive Fevers ..... Scarlatina—Cases CCL1II. and CCLXL '. Erysipelas—Cases CCLXII. and CCLXIII. Variola—Cases CCLXIV. and CCLXV. The ectrotic treatment of variola—Case CCLXVI Vaccination ..... Pathology of variola Diphtheria—Cases CCLXVII. and CCLXV in. Syphilis and Mercurial Poisoning—Cases CCLXIX. to CCLXXI. Forms of syphilis Diagnosis of syphilis . Propagation of syphilis Pathology of syphilis . XVI CONTENTS. Treatment of syphilis .... Rheumatism and Gout .... General pathology and treatment Treatment of acute rheumatism by nitrate of potash—Cases CCLXXII. toCCLXXV. .... Treatment of rheumatism by lemon juice—Cases CCLXXVI. to CCLXXIX. .... Diaphragmatic rheumatism—Case CCLXXX. . Rheumatic iritis—Case CCLXXXI. Chronic gout—Case CCLXXXII. Scorbutus—Cases CCLXXXIH. and CCLXXXIV. . Pathology and treatment Polydipsia—Cases CCLXXXV. and CCLXXXVI. . Polysarcia or Obesity—Case CCLXXXVII. Conclusion—The ethics of medicine Table of Cases ..... General Index ..... LIST OF ILLUSTKATIONS. Fig. 1. View of internal organs after removal of the thoracic and abdominal parietes 2. Deep-seated view of same . . . . . • • 3. Remarkable displacement of organs, in consequence of intestinal obstruction 4. Spatula? for depressing tlie tongue, one-third the real size 5. Extreme case of follicular pharyngitis .... . 0. Mode of using the laryngoscope and tongue-depressor i. View of the healthy larynx with the laryngoscope s. Another view of the healthy larynx during ordinary breathing «j. Another view duriug deep inspiration . 10. Complete closure of the glottis as in the act of swallowing . 11. Transformation of the right (inferior) false vocal cord 12. Cicatrices and loss of substance of the larynx . 13. Polypus attached to the right vocal cord 14. Large muriform polypus of an epithelial character in the laryr \ 15. Mode of inspecting the posterior nares 16. Voltolini's mirror and shield for depressing the tongue 17. Septum, posterior orifices of the nasal fossae, etc. 18. The stethometer of Dr. Quain, half the real size 19. Mode of applying the instrument when the string is used 20. The chest-measurer of Dr. Sibson, natural size 21 and 22. Modes of applying the chest-measurer 23. Stetho-goniometer, for measuring the inclination of the walls of the thorax 24. The pleximeter . . . . . . . 25. The percussion hammer of Winterich ..... 26 and 27. Anterior and views of the limits and intensity of dulness 28. View of percussion in phthisis, atrophied heart and liver, and abstinence 29. View of percussion in pleurisy ...... 30. View of percussion in pericarditis, pneumonia, and loaded rectum . 31. View of percussion in hypertrophy of liver and heart 32. View of percussion in hypertrophied liver and spleen—Enlarged heart 33. View of percussion in enlarged spleen—pushed somewhat upwards . 34. View of percussion in dropsy of the abdomen, enlarged heart, and aneurism 35 and 36. Anterior and posterior outlines of the trunk for marking results of percussion 62 37 to 41. Various kinds of stethoscopes 42. Flexible stethoscope ..... 43. Canman's stethoscope ..... 44. Differential stethoscope of Dr. Scott Alison 45. Hydrophone of Dr. Scott Alison .... 46- Oberhaeuser's microscope made for medical men 47. Gruby's compound pocket microscope . 43. The same microscope mounted, ready for use . 49. Beale's clinical microscope .... 50. Spaces equal to l-1000th and l-500th of an inch magnified 250 diameters linear 51. Salivary corpuscles, epithelial scales, etc., as seen in a drop of saliva . f>2. Minute confervoid filaments springing from an altered epithelial scale 53. Confervoid filaments and sporules, in exudation on the mouth and gums 54. Fringe-like epithelium, from the surface of an ulcer on the tongue . 55. Globules of cow's milk . . . . . . . . 56. Colostrum of the human female, containing milk globules greatly varying in size 57. Blood-corpuscles, drawn from the extremity of the finger 58. Blood-corpuscles altered in shape from exosmosis .... Page 34 34 35 33 38 40 40 40 40 40 '41 41 41 42 42 42 43 45 45 4li 4C 43 43 4lJ 54 55 56 57 M r/j rii xvm LIST OF ILLUSTEATIONS. Fig. 59, 60, 61, 62. 63, 64, 65, 66 68, 69, 70, 71 73. 74, 75, 76, 77 79 80. 81. 82. 83 85. 86. 87. 83. 89. 90. 91. 92. 93. 94. 95. 96. 97 99. 100. 101. 102. 103. 104. 105. 106. 107. 103. 109. 110. 111. 112. 113. 114. 115. 116. 117. 118. 119. 120. 121 123. 124. 125 130. 131. 132. 133. 134. 135. 136. 137. Page , Blood-corpuscles altered in form, and aggregated together, in thickened blood , The same united together in chaplets by coagulated fibrin . , Altered blood corpuscles in the fluid of an hasmatocele , Appearance of blood once observed in a case of cholera , Colorless corpuscles slightly increased in number Appearance of a drop of blood in leucocythemia , The same, after the addition of acetic acid . . ■ : . -, and 67. Pus corpuscles in healthy pus, and after the addition of acetic acia , Pus corpuscles, surrounded by a delicate cell-wall , Irregular-shaped pus corpuscles, in scrofulous pus . Mass, consisting of minute molecules, frequently seen in disintegrated tubercle and 72. Masses composed of molecules and oily granules varying in size Mass partly composed of the debris of a fibrous structure Mass composed of tubercle corpuscles . . Fragments of phosphate of lime occasionally found in the sputum . , Fragment of elastic tissue of the lung, in phthisical sputum . and 78. Fragments of areolar and elastic tissue, from phthisical sputum , Fibrinous coagula in sputum, exhibiting moulds of the bronchi Fibres, with corpuscles, in a fibrinous coagulum from a bronchus . Epithelial cells, embedded in mucus, expectorated from the fauces . Another portion of expectorated mucus from the fauces, acted on by acetic acid and S4. Cells loaded with pigment in the sputum of a collier Appearance of starch corpuscles after partial digestion in the stomach Flake in the rice-water vomiting of a cholera patient. Structures observed in certain rice-water vomitings from a cholera patient Sarcina ventriculi ....... Portions of the uredo in bread partly digested and disintegrated Structure of confervoid mass passed from the bovvels The same magnified 500 diameters linear .... Rounded masses of earthy matter ..... Structure offtakes in a rice-water stool, from a cholera patient Corpuscles seen in a chronic leucorrhoeal discharge . . Structure of gelatinous mucus from the os uteri The same, after the addition of acetic acid .... and 98. Two specimens of cancerous juice squeezed from the uterus . Viscid greyish-yellow sputa of pneumonia, treated with dilute acetic acid Spermatozoids as observed in the fluid of spermatocele Cells in fluid, removed from an ovarian dropsy Lozenge-shaped and rhomboidal crystals of uric acid Aggregated and flat striated crystals of uric acid Urate of ammonia, in a granular membranous form, and in spicular masses Triple phosphate, with various forms of urate of ammonia . Octahedral and dumb-bell shaped crystals of oxalate of lime Flat and rosette-like crystals of cystine .... Bodies observed in the urine of a scarlatina patient, 24 hours after being passed 105 105 106 106 106 106 106 107 108 108 108 108 10g 106 109 112 119 121 121 121 121 155 157 168 103 Cast of a uriniferous tube Fatty casts, at an early period of formation .... Fragments of fatty and waxy casts ..... Tyrozin masses in urinary sediment of a man with atrophy of the liver Leucin in a drop of the same urine allowed to evaporate Pure tyrozin from the same urinary sediment . Epidermic cells from crust of psoriasis . .... Thalli of the fungus found in the ear by Mr. Grove . The fungus {Achorion Schonleini) from a favus crust The same magnified 500 diameters linear .... Epithelial cells from the surface of an ulcer of the lip The same, after the addition of acetic acid .... and 122. Epidermic cells from a softened epithelioma . Appearance of section of cancerous ulcer of the skin . A pocket-case, containing a spirit-lamp, two stoppered bottles, etc. to 129. Development of vibriones ..... Nuclei embedded in a molecular blastema .... Young fibre cells formed by aggregation of molecules round the nuclei Cancer cells, one with a double nucleus .... Histolytic, or so-called granule cells, breaking down from fatty degeneration Remarkable atrophy of the left side of the face An exact copy of a portion of the web of a frog's foot inflamed Appearance of cartilage on each side of an incision made into the patella Vertical section of cartilage from the surface of the patella . 92 W2 93 i>3 93 94 94 94 95 95 95 95 95 96 96 97 97 97 98 98 99 100 100 101 101 101 101 102 103 103 104 104 104 104 105 105 LIST OF ILLUSTRATIONS. XIX Fig. Page 13?. Molecular fibres and plastic corpuscles, in simple exudation on a serous surface 165 165 165 165 165 166 166 166 167 167 139 and 140. Portions of recent lymph from the pleura 141. Portion of firm pleural adhesion .... 142- Another portion of the same, further developed 143. The last, acted on by acetic acid .... 144. Pus cells. Four cells have been acted on by acetic acid 145. Pus cells containing fatty molecules, after adding acetic acid 146 and 147. Scrofulous pus cells after the addition of acetic acid . 148. Granular exudation and granular masses, from cerebral softening 149. Granular cells and masses from cerebral softening 150. Two vessels coated with exudation from softening of the spinal cord . 168 168 170 171 174 175 175 17'J 151. Vertical section of a granulating sore 152. Moist gangrene, following compound fracture 153. Dry gangrene from debility . . . 154. Three air vesicles of a pneumonic lung with pus forming in them 155. Layers of lymph in pericarditis, presenting the form of large villi 156. Structure of the villi in pericarditis .... 157. Corpuscles from firm tubercular exudation into the lung 158. Corpuscles, granules, and debris, from soft tubercular exudation into cerebellum 179 l"a 130 ISO ISO 183 139 159. The same, from tubercular infiltration of a mesenteric gland . 160. Section of a firm miliary tubercle of the lung . 161. Section of a grey granulation in the lung 162. Molecular structure of a calcareous pulmonary tubercle 163. Structures in hypertrophied heart 164. Fibrous structure of the uterus . 165. The same, hypertrophied from great increase in size of its fusiform cells . 189 166. Cell fibres and fibre cells from a fibro cellular growth in the stomach . 189 167. Fusiform cells from a sarcomatous growth in the kidney . . . 189 163. Fibro-nucleated structure from a so-called medullary sarcoma of the humerus 189 169. Fibrous stroma of a tumor acted on by acetic acid .... 189 170. Fibres from induration of the stomach, with embedded nuclei . . 190 171. Fibrous tissue, with free nuclei and cells, from a white peritoneal patch . 190 172. The same, after the addition of acetis acid ..... 190 173. Cells in the soft part of a fibrous tumor removed from the neck by Mr. Syme 192 174. The same, after the addition of acetic acid ..... 192 175. Fibres in various stages of development from a harder nodule of the same tumor ' 192 176. Perfect fibrous tissue from another nodule of considerable density . . 192 177. Corpuscles scraped from the surface of a fibro-nucleated growth of the thigh 192 178. The same, after the addition of acetic acid ..... 192 179. Appearance of a thin section of the tumor ..... 192 180. Another section, treated with acetic acid ..... 192 181. Soft polypi growing from the Schneiderian mucous membrane . . 193 182. Fibre cells and fibres from the pulpy interior of a polypus . . . 193 183. The same, after the addition of acetic acid ..... 193 184. Ciliated epithelial and pus cells from the exterior of the tumor . . 193 1S5. The same, after the addition of acetic acid ..... 193 186. Section of a dermoid fibrous tumor embedded in the uterine walls . 193 187. Section of a dermoid fibrous tissue from the uterus, acted on by acetic acid 194 188. Section of hard uterine polypus, boiled in dilute acetic acid and dried . 195 189. Section of Neuroma connected with three nervous trunks . . . 195 190. Thin section of a subcutaneous tubercle composed of fibro-cartilage . 196 191. Fibrous structure of a neuromatous swelling ..... 196 192. Lobulated Lipoma of the nose . . . . . . .197 193. Smooth Lipoma, removed from under the tongue, one-half the natural size . 197 194. Two layers of voluminous fat cells, varying in size, from a Lipoma . . 198 195. Fat cells from the same, dried, showing crystalline bundles of Margaric acid 198 196. Section of a Fibro-Lipomatous tumor ...... 198 197. Simple cyst of the broad ligament of the uterus, with very vascular walls . 199 193,199. Diagrams of compound cystic growths ..... 200 200. Compound cystic sarcoma of the mamma ..... 200 201. Colloid cystic growths in three lobules of the thyroid gland . . - 201 202. Delicate oval corpuscles in transparent colloid matter of the ovary . . 201 203. Round and oval corpuscles with filaments in colloid matter in the ovary . 201 204 to 206. Of an ovarian cyst showing the epithelial cells, etc. . . . 201 207. Cells from the interior of a simple cyst ..... 202 208. Structure of cholesteatoma ....... 202 209. Encysted tumor, with fatty steatomatous contents .... 202 210. Contents of a large atheromatous cyst . ..... 203 211. Adipose cells, from a steatomatous encysted turner cf the ovary . . 203 XX LIST OF ILLUSTRATIONS. Fig. . raSe 212. Cysts in cystic sarcoma of the mamma, filled with molecular matter . 2u3 213. Fibrous tissue from a sarcomatous encysted growth in the kidney . . 204 214. Cystic osteoma of the femur ...-••• 204 215. Cystic osteoma of the tibia . . . • • •. ~°4 216. Cysts in cystic sarcoma of the mamma, crowded with cells . • • -0o 217. Fibrous stroma from another part of the same tumor . • • 205 218. Structure of a cystic glandular tumor of the neck .... 206 219, 220, and 221. Structure of a glandular tumor removed from the mamma . 207 222. New formed tissue in a follicle of the thyroid gland . . . • 208 223. Cells in fluid squeezed from a mesenteric gland, in a case of typhoid fever . 209 224. The same in another case . . . • • • 2^9 225. The same cells, after the addition of acetic acid . . . .209 226. Warts on the penis ..... ... 211 227. Summit of a papilla from a wart . . . . • • 211 228. Perpendicular section of a papilla, after adding acetic acid . . • 211 229. Transverse section of the base of a condyloma .... 212 230. Ulcerated epithelioma of the lip ...... 212 231. Section of an ulcerated epithelioma of the tongue .... 213 232. Muscular tissue immediately below the epitheliomatous ulcer . . 213 233. Concentric laminae of condensed epithelial scales . . . .213 234. Epidermic scales, in mass and isolated, from the scrotum . . .214 235. Group of deep-seated cells, in the same case ..... 214 236. The same, after the addition of acetic acid ..... 214 237. Fragments of the concentric masses figured Fig. 212, from a lymphatic gland 215 238. Epithelial cells, in yellow cheesy matter, of the same gland . . .215 239. Cells in white matter, from soft fuDgoid epithelioma of the urinary bladder 215 240. The same, after the addition of acetic acid ..... 215 241. Horn from an old preparation in the Edinburgh University Museum . 216 242. True saccular aneurism of the aorta, nearly filled with coagulated clot . 217 243. Remarkable spontaneous varicose aneurism ..... 217 244. Aneurism of the coronary artery, completely filled with coagulated clot . 218 245. Section of erectile tumor ....... 218 246. Varicose cutaneous vessels of the anus ...... 218 247 to 250. Of umbilical artery of calf, eight inches long .... 219 251. Common carotid artery of an embryo calf, showing directions of the fibre cells 219 252. Stellate cells in the tail of the tadpole, developing into capillary vessels . 220 253. Capillary vessels in different stages of formation, from the eye of foetal calf 220 254. Branched cells in lymph exuded on the peritoneum .... 220 255. Vessels in an early stage of formation, from a colloid tumor of the back . 220 256. Enchondroma of the hand and fingers ...... 221 257. Structure of a firm nodule in an enchrondroma of the humerus . . 221 258. The same, after the addition of acetic acid ..... 221 259. The cartilage cells and fibrous tissue separated, with numerous molecules . 221 260. Small cartilage with round granule cells in Solanoma . . . 222 261. The same cartilage cells, after the addition of acetic acid . . . 222 262. Thin section of a firm portion of the same tumor . ... 222 263. Fine filaments which interlaced the cells, these having been washed out . 222 264. Thin section of an enchondroma, with a bony capsule . . . 222 265. Separated cartilage cells from a softened portion of the same tumor . 222 266. The same, rendered more opaque, after the addition of acetic acid . . 222 267. Diseased articular cartilage ....... 223 26S. Similar alteration in costal cartilage of the dog .... 223 269, 270. Two fibrous projections, from the surface of a diseased human cartilage 223, 224 271. Lateral view of an exostosis ....... 224 272. Part of a section through one of the prominences of the tumor . . 224 273. Section of a portion of the tumor ...... 224 274. Spicular growth of bone, in an osteo-carcinomatous tumor of the tibia . 226 275. Epulis removed from the upper jaw ...... 226 276. Cells with many nuclei in epulis ...... 226 277. Fibro-cartilage between the separated portions of a fractured cervix femori-s 227 278. Spiculum of bone projecting from the choroid membrane . . . 223 279. Section from the centre of the crystalline lens .... 223 280. Loose membranous matter in the anterior chamber of the eye . . 228 281. Ossified excrescence on the arachnoid of the thoracic portion of spinal cord 223 282. Bony laminae arranged concentrically ..... . 228 283. Section showing the arrangement of cells and fibres in scirrhus of the mamma 229 284. The same, after the addition of acetic acid . . . . . 229 285. Isolated cancer-cells, from the same growth ■ • . . . 229 286. The same, after the addition of acetic acid . . . 229 LIST OF ILLUSTRATIONS. Fig 287. Young cancer-cells from the lung . . . . 2 288. The same, after the addition of acetic acid ..... 2 289. Somewhat older cells from the testicle ..... 2 290. The same, after the addition of acetic acid ..... 291. Still older cancer-cells from a tumor in the duodenum ... . 2 292. The same, after the addition of acetic acid ..... 293. Highest development of cancer-cells from a tumor of the toe 294. Simple and compound cancer-cells from the duodenum 295. Colloid tissue, with the loculi filled with molecular matter . 296. Colloid cancer-appearance of the fibrous areolae filled with cancer-cells 297. The same, after the addition of acetic acid ..... 298. Some of the cells isolated ....... 299. Fibrous stroma deprived of the cells by pressure and washing . . 2 300. Section of small cancerous nodule in the mucous coat of the stomach 301. Cartilage cells from a velvety articular cartilage of the condyle of the femur 302. Cells from a cancerous tumor of the brain . . 303. Fibre of the sterno-mastoid muscle, in the neighborhood of a cancerous growth 304. Fasciculi of muscle, forming the flap in an amputation of the thigh . 305. Granules, nuclei, and granule cells in a nerve ..... 306. Structure of the soft part of tumor removed by Mr. Page of Carlisle 307, 30S. Structure of the more indurated parts ..... 309. Structure of a fungoid growth of the leg ..... 310. The same, after the addition of acetic acid ..... 2 311. Structureless membrane formed by heating the clear fluid of pemphigus . 2 312. Edges of albuminous laminae, in a case of hydrocele .... 2 313. Dense fibrous structure, with naked nuclei from coats of the stomach . 2 314. The same, after the addition of acetic acid ..... 2 315. Diaphanous albuminous bodies, with fatty cancer cells from the diaphragm 316. Groups of blood corpuscles surrounded by an albuminous layer 317. A similar albuminous layer, round groups of bird's blood-cells 318. Substance of nerve tube, broken across, forming globules 319. Cells of the liver, in waxy degeneration of that organ 320. Section of the thyroid body, with its glandular sacs filled with colloid matter 321. Radiated colloid masses from a cyst in an atrophied kidney . 322. Fatty molecules in groups . . . . . . .2 323. Granular corpuscles and masses from cerebral softening 324. Granular corpuscles acted upon by pressure ..... 325. Early stage of fatty degeneration of voluntary muscle 326. Advanced stage of fatty degeneration in the muscular fasciculi of the heart 327. Another example of advanced fatty degeneration of voluntary muscle . 2 328. Fatty degeneration of the psoas magnus muscle of a lad with morbus coxarius 2 329. Other fasciculi of the same muscle, after the addition of ether . . 2 330. Enlarged fatty fusiform cells of the pregnant uterus after delivery . 331. Atheroma of a blood-vessel ....... 332. Fatty granules, oil drops, granule cells, and cholesterine in atheroma . 2 333. Transverse section through the coats of the popliteal artery of an aged woman 334. Cerebral vessels of an aged individual who died of apoplexy . . 2 335. Vessels from softening of the corpus striatum, coated with granule masses 336. Villi from the placenta of a six months'foetus . .... 337. Fatty granules coating the blood-vessels, within the placental villi . 338. Groups of fatty granules scattered through the substance of a placental villus 339. Fatty granules coating the vessels, and in the villous substance 340. Cells in fatty tracheal cartilage . ...... 2 341. Horizontal section of the occipital bone in a case of syphilis . 342. Thin section of the same bone, showing one of the cancelli . 343. Thin section of the outer table of the same bone .... 344. New cells formed in malacosteon ...... 345. Retrograde cells, granules, and granular masses, in the reticulum of cancer 2 346. Fatty and broken-down cancer-cells in reticulum of cancer of the liver 347. Fatty granular matter from the softened reticulum of a cancer of the breast 2 348. Liberated and altered nuclei in the reticulum of cancer of the testicle . 2 349. Crystals of hematoidine ........ S50. Wartlike brown ncevus mabemus of the female mamma 351. Atrophied bronchial cartilage, with deposition of brown pigment . 352. Placental villi, containing brown pigment from an aborted foetus . 353. Black pigment masses and molecules round a tubercle of the peritoneum . 354. Transverse section of a necrosed tibia ...... 355. Black pigment molecules from the lung ..... 356. Black pigment irregular masses, from an intestinal aggregate gland XX11 LIST OF ILLUSTRATIONS. Fig. 357. 358. 359. 360. 361. 362. 363. 364. 365. 366. 367. 368. 369. 370. 371. 372. 373. 374. 375. 376. 377. 378. 379. 380. 381. 382. 383. 384. 385. 386. 387. 3S8. 389. 390. 391. 392. 393. 394. 395. 396. 397. 398. 399. 400. 401. 402. 403. 404. 405. 406. 407. 408. 409. 410. 411. 412. 413. 414, 417. 418. 419. 420. 421. 422. 423. 424. 425. 426. 427. Polygonal cells loaded with pigment, from the surface of the pericardium Cells loaded with pigment, from a melanotic tumor of the horse Cells in a melanotic cancer of the cheek Cells in the black sputum of a collier . Calcareous incrustation of the small vessels of the brain _ . Structure of mineral degeneration of the walls of an aneurism Mineral degeneration of the nerve-cells and tubes of the spinal cord Mineral masses in a degenerated cancerous tumor of the omentum The same, in a degenerated cancerous mass in the liver Cancer-cells infiltrated with cretaceous molecules, in a mesenteric gland Mineral masses in a cretaceous tubercle of the lung . Section of an amorphous mineral mass .... Longitudinal section of an albuminous concretion Portion of one of the concentric lamella? of an albuminous concretion Transverse section of the edges of the concentric lamellae Section of the nucleus of an albuminous concretion . . Longitudinal section of an albuminous concretion magnified . Various forms of biliary concretions ..... Vertical section of renal tubuli filled with urate of ammonia. External view of a remarkable renal calculus .... Section of the same calculus, with nucleus of uric acid and oxalate of lime Calculus with lithic acid nucleus .... Triangular formed calculus of lithic acid .... Oval calculus of lithic acid ...... Oval calculus of uric acid . . . . . . The triple phosphate surrounding a mulberry concretion of oxalate of lime Nodulated mulberry calculus . . . . . Phosphatic calculus formed round a fragment of uric acid calculus . Phosphatic calculus formed round a piece of slate pencil Sections and external appearance of the calculi in Mr. Mackenzie's case Prostatic calculi ........ Mass of hair found in the human stomach .... Section of a remarkably shaped intestinal concretion Section of an intestinal concretion ..... Hairs from the caryopsis of the oat, in an intestinal concretion Amyloid bodies embedded in a seemingly amorphous matter The same, after dilution with water ..... The same, after the addition of acetic acid .... The same, after the addition of nitric acid .... Small corpora amylacea, in the auditory nerve of a deaf individual . Variously shaped and sized corpora amylacea, from the human pancreas Longitudinal plan of the arteries of the trunk . Transverse plan of the arteries of the abdomen opposite to the liver The same, lower down ....... Structure of inflammatory exudative softening of the spinal cord Structure of a tubercular exudation in the cerebellum Structure of the softened cerebellum ..... Structure of the softened cerebral substance .... Structure of the softened pons varolii ..... Amyloid bodies with fragments of nerve tubes, from the optic thalamus A blood-vessel from the substance of the brain coated with exudation Another blood-vessel also coated with exudation .... 388 Structure of a chronic grey softening of the cerebral hemisphere . . 389 Section of the capsule and coagulum of an old apoplectic clot . . 417 Granular corpuscles and masses in an old apoplectic clot . . .418 Peculiar vascular stroma with villi in cancerous masses of the brain . 423 Gland-like expansions of stroma in other portions of the same mass . 423 415, 416. Lateral, vertical, and front views of a hydrocephalic head . '. 424 Appearance of the gastric glands in recent catarrh of the stomach . . 493 Commencing cystic formation in a gastric follicle ..." 493 A cyst in the pyloric portion of the stomach . 493 Fatty degeneration of gastric glands in chronic catarrh of the stomach '. 494 Chronic catarrh of the stomach with hypertrophy of fibrous tissue 494 Fatty degeneration affecting the upper layer of gastric follicular epithelium 494 The gastric and pyloric glands hypertrophied in a cancroid tumor . 495 Disintegration of the hepatic structure following obstruction of the biliary ducts 505 Hepatic cells in various stages of fatty degeneration . . , 512 Structure of a thin section of liver in the last stage of cirrhosis 51 g Peri-lobular fatty or nutmeg liver .... 517 LIST OP ILLUSTRATIONS. XX11I Fig. 428. Pigmented nutmeg liver ...... 429. Remarkable carcinomatous cyst in the liver . . 430. Vascular congestion and sugillation of the small intestine in cholera 431. Granular mass, in recent exudation on the intestinal mucous membrane 432. An enlarged Payerian sac from the colon of a child 433. Flaccid pericardium with small amount of fluid 434. Distended pericardium, of a pyriform shape . 435. Excessive distension of pericardium 456. Conjoined attachment of two of the aortic valves 43 7. Aortic orifice with one valve of a funnel-shape 438. Two valves of the aortic orifice, with a rudimentary one interposed 439. Congenital malformation of the aortic valves .... 440. Fouf valves at the aortic orifice from the adhesion of one 441. Five valves formed from adhesion and production of the septae in two valves 442. Button-hole contraction of the mitral orifice .... 443. Mitral orifice, greatly constricted, forming an oval aperture . 444. Fibrinous vegetations, and atheromatous degeneration of the aortic valves 445. Rough sketch of innominatal aneurism and adjoining parts . 446. Diagram of an aneurism of the arteria innominata 447. Aneurism of the thoracic aorta and superior mesenteric artery 443. Appearances in acute laryngitis and oedema glottidis . 449. Plug of mucous or coagulated blood in a bronchus 450. Remains of pleural abscess ..... 451. Relative position of the thoracic and abdominal viscera in A. Brown's case 452. Vertical section of a lung affected with pleuro-pneumonia 453. Two moulds of coagulated exudation in red hepatisation of the lung 454. Fragment of chicken-bone found in the right bronchus, in Neal's case 455. Fluid in the chronic abscess of the right lung, in Neal's case 456. Part of the left lung with clots occupying branches of the pulmonary arter 457. Section of a lung in the first stage of phthisis pulmonalis 458. Section of a lung in the second stage of phthisis pulmonalis 459. Section of a lung in the third stage of phthisis pulmonalis 460. Section of the summit of the right lung in arrested phthisis 461. The section of the upper portion of the lung in Keith's case seen from within 462. Chyle from the thoracic duct of a dog, three hours after eating a meal 463. Corpuscles in cancerous juice squeezed from the thyroid body 464. The same after the addition of acetic acid .... 465. Vertical section through the wall of an ovarian cyst . 466. Subsequent formations proceeding in the walls of simple cysts 467. Section of the wall of an ovarian cyst, with epithelial cells in situ . 468. Polygonal epithelial cells from the same lining membrane . 469. Oval epithelial cells from the lining membrane of an ovarian cyst . 470. Cells in fluid removed from an ovarian dropsy 471. Groups of columnar epithelium, etc., in encephaloma of the ovary . 472. Diaphanous celloid bodies, naked nuclei, and granule cells in the same 473. The nuclei after the addition of acetic acid .... 474. Structures occasionally seen in cysts of the kidney 475. Waxy degeneration of a malpighian body, with a few granule cells . 476. Structures in a fatty kidney 477. Portion of fatty renal tube 478. Longitudinal section of a fatty kidney 479. Transverse section to the former one 430. Exudative casts of renal tubes . 481. Desquamative casts, with blood corpuscles, naked nuclei, and cells . 482. Fatty casts of renal tubes with granule cell .... 483. Waxy casts of renal tubes of various sizes . 434. Dorsal surface of the female Acarus Scabiei .... 4S5. Ventral surface of the same ...... 4«6. Ventral surface of the male Acarus ..... 4S7. Three follicles of the skin of the dog containing entozoa 4«8. Cul-de-sac of a sebaceous follicle, with entozoa and ova 4*9. Hair and its follicle, with entozoa ..... 490. Crusts of favus in different stages of development 491. Branches of the Achorion Schomleini, in an early stage of development 492. Fragments of the branches more highly developed 493. A light hair, containing branches of the Achorion Schoinleini 494. Sporules developing on the surface of an apple, after three days 495. The same, after four days . . . . 496. The same, more fully developed on the human arm, after inoculation Xxiv LIST OF ILLUSTRATIONS. Fig. 497, 498, 499, 500, 501, 502. 503. 504. 505, 506, 507. 508. 509 510. 511. 512. 513. 514. 515, 516. 517. 518. 519. 520. 521. 522, 523. 524. 525. 526. 527. 528. 529. 530. 531. 532, 533 535. 536, 537, Thalli, mycelia, and sporidia, of the Achorion Scheenleini . Thalli and sporules from chronic pityriasis of the scalp Microsporon Furfur, in pityriasis versicolor . Portion of the root of a hair plucked from a crust of chronic eczema Portion of clot from the vena cava in leucocythemia . Posterior surface of the aorta and vena cava in leucocythemia . Appearance of the cerebral hemispheres in a case of leucocythemia . Colorless corpuscles, mingled with a few colored ones The same bodies, mingled with a larger number of yellow blood corpuscles Change produced on the colorless corpuscles on the addition of acetic acid Cells in the fluid squeezed from the lymphatic glands Blood-vessels giving off a capillary from the pia mater Appearance of a drop of blood in leucocythemia The same after the addition of acetic acid The same after the blood has stood for twenty-four hours Colorless corpuscles slightly increased in number The same after the addition of acetic acid Colorless corpuscles increased in number, and of small size The same after the addition of acetic acid Colorless blood-cells observed in leucocythemia Development of the nucleus in colorless blood-cells . Cells of various sizes, in the blood of a haddock, frog, and turkey The nuclei of the blood-cells of the haddock, frog, and turkey Fluid chyle, mingled with water .... The same, after the addition of acetic acid Numerous naked nuclei of the colorless corpuscles in the blood The same after the addition of acetic acid Cells with single and multiple nuclei .... Structure of a decolorised mass in spleen The same after the addition of acetic acid Appearance of exudation and epithelial cells in the typhoid lung Another portion of the same lung, after the addition of acetic acid Portions of normal epithelium separated from the air vesicles A clinical ward of the Royal Infirmary, with fever beds, in 1817 Clinical ward, No. XL, 1858, with present arrangement of fever beds ; Mr. Weir's scarificator for vaccination and 534. Dr. Husband's tubes charged with vaccine lymph Skeleton of a dog poisoned by mercury Exostosis of dogs femur .... Internal view of the same .... 860 865 865 866 » CLINICAL LECTURES. INTRODUCTION. Gentlemen,—Medicine, as a subject of study, must be regarded in a two-fold aspect, as a science and as an art—it has its theory and its practice; its principles and their application. We can trace the germs of theory and practice in medicine to a very early period. At first, indeed, the art must necessarily have been founded upon experience and observation alone. Hippocrates first added philosophy and reasoning to experience, and introduced those discussions which led to the overthrow of empiricism, and the final triumph of dogmatism, six hundred years later, in the time of Galen. Since then, although the medical profession has uniformly conjoined the results both of reasoning and experience, each of these two methods has had its special supporters. Even at the present day you will find persons who complacently call themselves prac- tical men, and who sneer at all modern advances in pathology. Others are apt to attribute too much importance to theory, and regard with feel- ings approaching to contempt him whom they denominate a routine practitioner. Hence, unfortunately, it too often happens that practical men are comparatively unacquainted with physiology and pathology; while those who dedicate themselves to the latter studies are very scep- tical as to empirical remedies. On this subject Cullen made a remark eighty years ago which applies at present:—" Every one now-a-days pretends to neglect theory, and to stick to observation. But the first is in talk only, for every man has his theory, good or bad, which he occa- sionally employs ; and the only difference is, that weak men who have little extent of ability for, or who have had little experience in reason- ing, are most liable to be attached to frivolous theories ; but the truly judicious practitioners and good observers are such as have the most extensive views of the animal economy, and know best the true account of the present state of theory, and therefore know best where to stop in the application of it." If these observations were correct when Cullen wrote, they are far more applicable now, when almost every advance that has been made in the art of medicine since his day has been owing to the result of scientific investigation. But in order to make this proposition clear, allow me, in the first place, to point out what I conceive to be 1 2 INTRODUCTION. The Relation of the Science to the Art of Medicine. If we regard the whole field of human knowledge, and reflect on the differences which exist among the various sciences, we must insensibly be led to classify them into two great divisions, viz., the exact and the in- exact. All the sciences belonging to the first class are characterised by the possession of a primitive fact or law, which, being applicable to the whole range of phenomena of which the science consists, renders its dif- ferent parts harmonious, and the deductions of its cultivators conclusive. Thus, the physical sciences possess a primitive fact in what is called the law of gravity. It was Sir Isaac Newton who demonstrated, by a happy effort of genius, that all the planets in our system gravitate towards the sun by the same law, and in consequence of the same principle, as that by which bodies on the earth gravitate towards its centre. This theory was subsequently found applicable to a vast number of circumstances, and by it the philosopher now explains many of the material phenomena of the universe, and the astronomer calculates the movements of the heavenly bodies. This law applies to all the facts of which physical science is made up. In the same manner, chemistry possesses a primi- tive fact in what is called the law of affinity, discovered later by Lavoi- sier. If we mix two salts which mutually decompose each other, a third salt is formed by the union in definite proportions of their constituent elements. This, in the language of chemists, is brought about by chemical affinity. If we repeat the experiment a thousand times, the same result takes place, and the law, which applies in one case, is found universally applicable to every phenomenon in chemical science. The possession of this primitive fact, then, communicates the greatest accu- racy and precision to the sciences which possess it, and on this account they are called the exact sciences. But there are other sciences which are altogether destitute of a pri- mitive fact; which consist of groups of phenomena, each of which may or may not be governed by a particular law. Such a one is agriculture. No man, however skilful, can till the ground or cultivate the soil, and be certain of the same result on every occasion. Numerous circum- stances, over which he has no control, may destroy his anticipations and show the fallacy of his calculations, and this, after every known condition has been fulfilled, and every possible degree of prudence and sagacity has been exercised to ensure success. The same means, appa- rently, which operate at one time fail to do so at another. Such sciences, then, are denominated inexact sciences, and it is to this class that medi- cine belongs. Now, the cultivators of medicine always have been, and are still endeavQring to render the science exact; and hence at various times individuals have brought forward what they conceived to be a law or primitive fact, and have tried to show that it was applicable to all vital phenomena. "Some have placed the law in the physical condition of the solids, and others in the physical condition of the fluids. Hence the terms solidists and fuidists. A third party have sought it in the func- tional conditions of the body, viz., an alteration in the living force. They have been called vitalists. If, for instance, we could constitute the RELATION OF THE SCIENCE TO THE ART OF MEDICINE. 3 vital property, excitability, a primitive fact, it would serve the same pur- pose in physiology that gravitation does in physics. But we cannot do this. It is true that the stomach is excited by the food, in order that digestion may be produced, and that the lungs are excited by the air during the process of aeration. But in the performance of these func- tions, excitability plays a secondary part; it is only one of the elemen- tary properties necessary for their completion, and is utterly insufficient to account for their production. In the same manner, neither the mechanism of the solids nor of the fluids can explain every known fact; so that it becomes necessary to take all three doctrines,—solidism, humoralism, and vitalism,—into consideration, if we wish to escape fallacy. Of late years it has been contended that, as far as structure and development are concerned, we do possess a law in the doctrine of cyto-genesis, that is, of the growth of those minute vesicles or cells, of which we find all grants and animals, at one period of their existence, to be composed. It has been argued that if a theory of organization can be shown to apply to all animated nature, to the vegetable as well as to the animal kingdom ; if it can be demonstrated that the humblest and minutest tribes of plants possess the same original structure as is to be found in the most gigantic trees of the forest; if it become evident that the same principle of formation is discoverable in animals, whether so minute that thousands may be contained in a drop of water, or, on the other hand, so enormous as the elephant or whale; nay, more, if it admit of demonstration that the organic diseases to which they are subject, that the formation of new growths and the reparation of tissues are explicable by the same theory as applies to the development of healthy structure,—then, it is contended, we are surely approaching to something like a great primitive fact, which may ultimately communicate exactitude to physiological science. And yet, notwithstanding the flood of light which has been thrown upon all departments of our science by the beautiful generalisation of Schleiden and Schwann, recent researches have exhibited its insufficiency to ex- plain all known phenomena of growth. Medicine, then, in its present state, possesses no primitive fact. But is it not very possible that it may do so at some future time? During the many ages that existed before Newton, physical science was as inexact as that of physiology is now. Before the time of Lavoisier, chemistry, like physiology, consisted of nothing but groups of pheno- mena. These sciences wenb on gradually advancing, however, and accumulating facts, until at length philosophers appeared who united these together under one law. So medicine, we trust, is destined to advance, and one day another Newton, another Lavoisier, may arise, whose genius will furnish our science with its primitive fact, and stamp upon it the character of precision and exactitude. Although it must be confessed that we have not yet arrived at such a happy consummation, it cannot be denied that we are making rapid strides towards it. Notwithstanding those principles which Bacon intro- duced into the study of science, it is only lately, from the advance of collateral branches of knowledge, that we have been enabled to catch 4 INTRODUCTION. glimpses of a correct philosophy as applied to physiology. A truly scientific medicine is yet to be created—for all the processes of life, both in its healthy and diseased conditions, are really owing to the structures which have been only lately made visible by the improvement in optical instruments. We know also, that these processes are connected with physi- cal and chemical changes, the importance of which we are just commenc- ing to estimate. But now, assured of what is really necessary, and guided by rigid observation and experiment, rather than by a vague hypothesis, physiology and pathology are advancing with such rapidity that every year improves or modifies the ideas which sprang up in the one which preceded it. Moreover, it has been satisfactorily shown that the branch of science which refers to vital phenomena bears such a relation or correlation to various branches of physical science, that the whole is gradually becoming more simple, instead of more complex. Instead of physiology being isolated under the idea that its laws are peculiar, it is every day becoming more evident that vegetable and animal life are de- pendent on conditions which, strictly speaking, are elucidated by the geologist, botanist, zoologist, chemist, and natural philosopher. In short, the intimate union of the natural sciences seems to be near at hand. But you do not cultivate these sciences as barren, however interest- ing, subjects of medical study. With you, I apprehend, as with myself, the knowledge so acquired constitutes a groundwork for the practice of an art. It is in this point of view I am especially anxious you should consider physiology and pathology. For, gentlemen, I trust that, in studying these subjects, you will never lose sight of the important fact that you are medical students, and that, as such, your ultimate object is to acquire an art; in other words, skill in the employment of all those means which are directed to the prolongation of life and the cure of diseases. Now, in order that you may successfully accomplish this great object, it is necessary that you should appreciate properly the importance of theory in its bearings on practice, so that, when you are called upon to treat the sick, you may be ready to take advantage of all the knowledge which you may have obtained. Hence the importance of knowing how to distinguish between the nature and object of science and art respec- tively. We may consider science, then, to be a collection of theories; art, a body of rules. Science says, this is or is not; this is probable or improbable. Art says, do this, avoid that. The object of science is to discover facts and determine laws; the object of art is to accomplish an end, and determine the means of effecting it. Science is inductive, and reasons; art is imitative, and exemplifies. Science is steady, certain, and progressive; art is vacillating, doubtful, and limited. Hitherto it has been imagined that the chief, if not the only method of obtaining skill in art is by practising it; that is, obtaining experi- ence. In medicine this is proverbial, and every practitioner is more apt to boast of his experience than of his scientific knowledge. In the infancy of science, indeed, we can readily understand that its hasty generalisations must have been continually overthrown and rendered ridiculous the moment they were applied to practice. Hence the reason why art for many ages preceded science—why dogmatic rules were more RELATION OF THE SCIENCE TO THE ART OF MEDICINE. 5 attended to than ingenious theories—and why the accomplishment of an end, even when that end was limited, was more regarded than the dis- covery of a new fact, or the determination of a law capable of extensive application. But in recent times this state of things is gradually be- coming reversed. Science, in numberless instances, has advanced beyond art; nay more, science herself has worked out all the details, and made an art obedient to her commands. Thus it was that the theory of achro- matism, worked out by Euler, led opticians to make perfect telescopes and microscopes. Thus it was that Le Verrier and Adams, by calcula- tions in their observatories in Paris and London, discovered a planet which they had never seen, but which, when looked for, according to their directions, from Stockholm and St. Petersburg, was immediately proved to exist in fact, as it had previously been proved to exist in theory. Thus it was that the electric telegraph, perfected in the closet of the man of science, flashed ready-made on the astonished gaze of an admiring world ; and thus it is that at the present moment we see the artizan in his workshop, the explorer in the mine, the agriculturist in his farm—nay, even the sculptor in his studio—abandoning the rules and wise saws handed down to him from ancient tradition, and accommodat- ing himself to the revolutions which science has dictated, and those laws whereby blind experience is made to yield to an enlightened knowledge. We may therefore receive it as an established law, that the more any particular science is advanced, the more is the art to which it leads rendered perfect, and that true theory in the one produces never-failing rules in the other. The art of navigation, for instance, is certain, in so far as it is based on the science of astronomy, which admits of exact calculation. In like manner, the only way of improving the art of medicine is to advance the scienc6 of physiology; and all that has been accomplished during the last fifty years has been brought about in this manner. In that short time have been discovered the independent pro- perties of the nerves, the reflex functions of the nervous centres, the chemical balance of organic nature, the functions of cells and their in- fluence on nutrition and secretion, the laws regulating the development of the ovum, the significance of the sounds produced by the heart and lungs, and numerous other doctrines which have tended to improve the art of medicine. But while the modern cultivator of medicine loses no opportunity, and employs all the means with which the improved state of science furnishes him, for investigating morbid anatomy and the causes of dis- ease, he carefully corrects the theoretical conclusions to which these alone might lead him by practical experience and observation. Our active and our speculative powers should go hand in hand, so that, by a union of theoretical knowledge and practical skill, we may advance both to their-farthest limits. It is by cultivating medicine in this spirit that the clinical school of Edinburgh has rendered itself so famous. Those who taught the theoretical branches of medicine from their chairs in the University were those who taught the practice in the wards of this Infirmary. They were thus enabled to demonstrate how, on the one hand, correct observation leads to just deduction, and on the other, how a knowledge of general principles causes accuracy and acuteness in INTRODUCTION. observation. Indeed, it is impossible to estimate too highly the advan- tages which have resulted from such a system, which has been carried on uninterruptedly by the Professors of this University, for one hundred and ten years. This leads me to speak of The Mode of Conducting the Clinical Course. Your principal object, gentlemen, in coming into this Hospital, is, I presume, to observe disease for yourselves. Now,. to observe with advantage two things are necessary: 1st, The correct appreciation of actual facts, as communicated to the senses of the practitioner or of his patient; 2d, The deduction from these of a correct judgment as to the nature of the disease, and the proper mode of its treatment. Both these processes are very difficult of attainment, and some men have a natural aptitude for the one and some for the other. They are also frequently confounded together, some observers considering those to be facts which are only theories, and others imagining that to be theoretical which is truly fact. Thus the assertion that a man is laboring under apoplexy, pneumonia, pericarditis, and so on, is only stating the opinion or theory the practitioner holds with regard to his case, although such assertion is generally received as a fact. Again, when it is said that porrigo favosa consists of vegetable fungi growing on the scalp, the statement, though generally received as mere theory, is truly a fact, inasmuch as the vege- tation may actually be demonstrated, and rendered as visible to the eye as trees growing in a plantation. Indeed, the just distinction between theory and fact is a matter which has excited lively discussion, and hence the celebrated saying of Cullen, that there are more false facts than false theories in medicine. ^ If, in the field of medical observation, we define a fact to be any- thing which is obvious to the well-cultivated senses of the observer, we perhaps approach as near accuracy as is possible. Remark, I say well- cultivated, because the senses require to be educated before they can receive proper impressions. In this lies the great difficulty in teaching practical medicine, for what is obvious to the sight of an experienced practitioner is overlooked by the student; the sound which is heard by the one is inaudible to the other; what the first feels distinctly is not perceived by the second. Now, this instruction of the senses constitutes , a kind of information which cannot be obtained from others; you must acquire it for yourselves. Of late years, however, the detection of facts has been greatly facilitated by the appropriate use of instruments, whereby what at one time was conjectural is now rendered certain. Thus, the existence of many diseases, which could formerly be detected only by a happy speculation or by a rare sagacity, is easily demonstrated by those who know how to employ judiciously chemical tests micro- scopes, stethoscopes, pleximeters, specula, etc. To carry observation, then, to its utmost extent, we must learn how to avail ourselves of all these means in the examination of the signs and symptoms of disease On the other hand, gentlemen, a sound and correct judgment' is equally necessary, in order that the cultivation of the senses may lead to MODE OF CONDUCTING THE CLINICAL COURSE. 7 a proper end, and indicate the direction in which you must act for the benefit of the patient. For this purpose a certain degree of preliminary instruction is absolutely essential before you can be qualified to attend an hospital with advantage. Indeed, I must take it for granted that before coming here you are tolerably well acquainted with anatomy and chemis- try ; that you have studied the institutes of medicine—that is, the present state of histology, physiology, and pathology; and that you have a know- ledge of the materia medica, and of the effects of remedies on the economy. Thus prepared, you commence a series of visits to the bedsides of those who are laboring under disease ; in other words, you enter upon a course of clinical instruction. What should we understand by clinical instruction ? It is not attendance on the lectures only—it is not merely learning the opinions of your teacher—it is not simply deriving know- ledge from others. It is acquiring medical information for yourselves— it is the learning how to observe—it is that education of the senses to which I have alluded; and, in addition, the formation of that sound judgment which will enable you to act for the benefit of your patients. This can only be learned by continual practice and experience; and it has always appeared to me that the great aim of clinical instruction should be to teach the student to acquire that kind of tact and readiness to do, which we have seen constitutes art. How are all arts acquired ? A young mechanic, when he makes a chair, follows exactly the same process as those who stud^ what are called the fine arts; that is, he learns how to do what his master did before him. He imitates his plan of proceeding. His first attempts are rude and uncouth; his subsequent ones are more perfect, until at length, by continual practice, he is enabled to equal or surpass his instructor. In painting, sculpture, and music there are principles which must be attended to, and which are learned from others; but no man can become a painter, a sculptor, or a musician without obtaining practical skill as an artist in the way now alluded to. It is thus, and thus only, that art de- scends from the old to the young. And so in medicine; it is not enough to obtain general views of health and disease, or to study what is known of the nature and treatment of individual maladies. It is absolutely essential to watch diseases for yourselves, to see the altered countenance and form, to feel the variations in the pulse and temperature of the sur- face, to hear the changes which the sounds of the heart and lungs undergo, to learn the employment of stethoscopes, microscopes, and other mechani- cal aids in investigation, and to adapt those remedies which are in use to the special case before you. It is only by a combination of such training in a hospital for the sick, with the varied scientific knowledge you have obtained elsewhere, that you can hope to prepare yourselves conscientiously for the responsible duties of a medical practitioner. The best hospital arrangements for clinical teaching are those which exist in Italy. All the cases admitted are first placed in a receiving ward (depositorium), and immediately visited by the clinical professor or his assistant. From these he selects daily such as he thinks best fitted for clinical instruction. He has seldom above thirty beds himself, a number amply sufficient if he possesses the right of choice. Thereby he is enabled to bring before his students examples of nervous, cardiac, pul- 8 INTRODUCTION. monary, renal, or other diseases, multiplying illustrative cases of each in his wards as he requires them. The result is, that when lecturing on phthisis or any other malady, he is enabled to direct the attention of his pupils to groups of cases presenting the various stages and complications which characterise it. He can thus demonstrate the physical signs and symptoms of the disease in all its forms; point out the numerous varieties it exhibits, and show the differences in treatment which are necessitated by varied circumstances. I need not say that the proper selection of cases for clinical instruction is a matter of great importance, because, if not sufficiently varied, the student cannot, in the limited time at his dis- posal, take a sufficiently extensive grasp of medical practice.* In many schools, especially abroad, there are separate professorships of clinical medicine ; whereas in others clinical teaching is carried on by the professors of other branches of medical education. Of the two sys- tems I have no hesitation in preferring the latter. Those practical phy- sicians who teach annually the theoretical and systematic branches of medi- cine ought to be those best qualified for giving instructions in an hospital, and this for the obvious reason, that they are obliged to keep on a level with the advancing knowledge of the day in at least one department of science. They may, it is true, bring different kinds of knowledge to bear on the subject, but that knowledge will be the best in its way, and the students will have the advantage of observing diseases treated by each in turn. This system has been found, on the whole, to answer well, al- though it must be admitted that periods of three months are too short for a clinical teacher and his pupils to work together in the course of a twelvemonth. On the other hand, a single professor is too apt to pass into a system of routine, to dwell only on his own peculiar views, and, not being required to teach any science, gradually to fall behind, and then lose sight of scientific advancement altogether. Now it is the union of science and art which stimulates both to reach their highest degree of perfection. The physician who teaches the former systematically in the university is the man who will correct and enlarge his theory in the wards of an hospital, and he who possesses a large practice and great ex- perience will extend his resources by keeping himself an courant with the state of science, as is necessitated by his duties in the university. I be- lieve that these are the reasons which have rendered the clinical school of medicine in Edinburgh so celebrated. As to the methods of teaching, they essentially consist of two kinds. In one the professor gives lectures to the students suggested by the cases under treatment, to which are occasionally added, during his visits at the hospital, observations at the bedside. In the other the student is encouraged to talk to the teacher; to examine the case for himself, form his own diagnosis, and suggest a treatment. Both systems have their advantages and disadvantages. An experienced teacher pointing out the difficulties and peculiarities of particular cases, and enriching the whole with the results of his own * The Medical Faculty of the University, in surrendering several years ago the same choice as is still possessed by the Italian clinical professors, were guilty of an injudicious liberality which has much weakened the efficiency of its hospital instruc- tion. MODE OF CONDUCTING THE CLINICAL COURSE. 9 observations made in a large field of hospital and private practice, cannot but communicate to his hearers most useful information, that in after years should prove of the utmost value to them. Unfortunately the students who hear such lectures are seldom prepared to benefit by them. The difficulties of the experienced, and the methods by which they are to be overcome, cannot be entered into by those who have no experience at all. Nay, more; the very facts and language on which descriptions are based in the class-room are often unintelligible to the student. I remember myself listening to a most able lecture on the diagnosis of pleurisy, the whole of which depended on knowing whether friction sounds and certain modifications in the vocal resonance did or did not exist. But as I had no clear idea—indeed was profoundly ignorant—of what these sounds and vocal modifications were, I was not much the better for the information communicated to me. In this manner it too frequently happens that, at the end of a series of clinical lectures, though the student has heard and seen much, he in truth knows very little, and has in fact all his real practical knowledge to acquire. The other mode of clinical teaching I first became acquainted with in the wards of M. Rostan in Paris in 1837, and subsequently saw it carried to a high degree of perfection in the great Cliniques of Germany —especially under Schonlein, Wolf, and Barez, in the Charite Kranken- haus of Berlin. It consists in calling upon a student to examine the case before the class, in the presenco of the teacher, according to a well- understood plan. At the termination of the examination, he is asked to give his opinion or diagnosis as to its nature. Those who stand round, and who have followed all the steps of the examination, are also invited to give their opinion. This gives an opportunity to the teacher of pointing out the error of this view or the correctness of that, until a sound conclusion is arrived at. Then the student is asked to suggest a treat- ment. Again, suggestions on this point are solicited, and the one con- sidered best is adopted by the physician for such and such reasons. Finally, the student is requested to prescribe, and taught how to do so correctly. In Germany, the examining pupil is further requested to write out the case, and to keep a record of it, which is subsequently corrected as an exercise by the professor. It must be apparent that in this manner a student will acquire a large amount of practical informa- tion. On the other hand, instruction entirely carried on in this manner deprives the student of much that is valuable, because there are many topics which obviously cannot be carefully considered at the bedside, and others which a sense of propriety should prevent being discussed in the patient's presence. In fatal cases, a most important part of clinical instruction consists in carefully examining the dead body, and from the appearances observed determining how far the diagnosis and treatment have been correct. This evidently cannot be carried on in the wards, and is practically useless to those who have not previously seen the case. The system of instruction, therefore, I have carried out for the last seventeen years in this infirmary is one in which I endeavor to adopt the excellences and avoid the defects of both systems. On Tuesdays and Fridays I lecture in the hospital theatre, in which I give a resume, 10 INTRODUCTION. of the facts of special cases; dwell on any difficulties of diagnosis or treatment that have presented themselves; refer to the experience of other physicians; discuss pathological doctrines; and, above all, exhibit the morbid parts of fatal cases, and connect the changes observed in the organs after death with the phenomena we have studied in the living. On Mondays, Wednesdays, and Thursdays I visit with you all the cases in the wards, and call upon such of you as wish to examine for your- selves to do so, according to the plan which you will find detailed in this little book, " An Introduction to the Study of Clinical Medicine." You will then try and form your own diagnosis, and propose a treatment. In doing this, numerous opportunities will present themselves which will enable me to give you practical instruction in percussion, ausculta- tion, the use of the microscope, and of chemical tests at the bedside. You also will gradually learn how to put questions, and so conduct the inquiry as to arrive at an exact result with as little fatigue to the patient as possible. On Saturdays and Sundays only the more urgent cases will be visited. Gentlemen, I am happy to say that this system has met with the highest approval from the large classes I have had the honor to instruct. In 1849, the gentlemen then attending informed me in this memorial that, " Being aware how every divergence from the regular medical routine is very generally regarded at first with suspicion, we feel it our duty to express the conviction that, in our experience, the system alluded to has operated most beneficially, and to hope that future students may enjoy its advantages." In 1850, a numerous class spontaneously pre- sented me with this testimonial, in which they say—" We do not hesitate to inform you that we have learned more of practical medicine by your mode of teaching than by any other mode in use; and though objections have been raised against it, we feel certain that the records of these last few months will tend to remove them. The general decorum of the class at the bedside; the great interest exhibited in the cases; and last, though not least, the never varying good attendance, all speak loudly in its favor, and will, we trust, encourage you in your zealous exertions to promote the science of medicine by the sound instruction of its youthful votaries in its theory and practice." Encouraged by these marks of approval, I have continued my method of clinical instruction up to this time, generally devoting two hours to my practical teaching in the wards, and have never heard from pupil or patient the slightest objection. The latter, indeed, is uniformly con- tented, being wise enough to know, even by instinct, that a careful and minute examination of his case can only be productive of benefit to him. Strange to say, however, objections have recently been made from a quarter whence I least expected them; ridicule and misrepresentation have not been wanting to give point to the attack; and another system of clinical instruction has been brought forward, which is considered preferable to any other. The chief objection is, that the examination of a patient before a large class and by an inexperienced student is cruel to the patient. " There could not, I think," says the objector, " be any procedure more shocking than propping up a poor creature suffering from disease of the MODE OF CONDUCTING THE CLINICAL COURSE. 11 lungs, and hammering his chest for the recognition of diagnostic sounds as an academic exercise." This passage, which I copy from the Edin- burgh Evening Courant for December 13th, 1863, may have a formi- dable appearance to the public who read it in the newspapers, but will certainly not prevent physicians and intelligent students from practising percussion in diseases of the chest. The reference to this class of diseases also is singularly unfortunate; for it is just in consequence of the exactitude with which we now arrive at a knowledge of them by the " shocking " process referred to that those, formerly so fatal, are now almost always subdued. The "hammering" of every case of acute pneumonia in my wards is followed by the rapid recovery of the patient. Even phthisis—that formerly hopeless disease—is now much disarmed of its terror. Besides, in the system of teaching I am advocating, the professor is always present to check any unnecessary trouble or incon- vience that might be given to the patient; and in all acute cases, such as of fever or acute inflammations, no examinations not absolutely re- quired are allowed. The plan'of clinical instruction which has been proposed as " prefer- able and as worthy of general adoption" is as follows—viz., " to bring the cases one by one into a room where the students are comfortably seated, and if the patients have not been seen previously by the surgeon so much the better. Then ascertain the seat and nature of their com- plaints, and point out the distinctive characters. Having done this so that every one present knows distinctly the case under consideration, the teacher, either in the presence or absence of the patient, according to circumstances, proceeds to explain the principles of treatment, with his reasons for choosing the method preferred, and, lastly, does what is re- quisite in the presence of his pupils." Without denying, as before stated, that a large amount of instruction may thus be communicated, I still venture to doubt whether those who are taught in this way will ever be enabled to grapple with the realities of practice. I remember, when myself a surgical student in this infir- mary, looking at the brilliant operations of Messrs. Liston, Syme, Lizars, and Fergusson. Legs and arms flew off with the rapidity of lightning, as if by magic; and what the bewildered student mainly occupied him- self with was his watch, to determine in how many seconds the opera- tion was completed. But as to performing such an operation him- self, the thing was never thought of nor inquired into. Further, if it be " shocking " to examine medical patients physically in their own beds, what term ought to be applied to dragging persons with fractures, dislocations, wounds, and sores from their beds, into a room where the students are comfortably seated ? Indeed, it is easy to understand how those who receive instruction in a practical art after this fashion—who seldom visit the wards or follow the progress of disease there, and who only see just so much of a case as the teacher places before them in the manner above-mentioned—must be very liable to present those appear- ances so well described by Dr. Parkes, when subjected to a practical ex- amination.* * See report of Speech made to the Medical Council April 30th, 1864, in all the weekly journals. He contended that the medical corporations were admitting men 12 INTRODUCTION. The only method of giving a stimulus to the practical education of students in the hospital wards is to institute practical examinations for their diplomas or licenses. Those, however, who are opposed to practi- cal teaching, and in favor of the comfortable looking-on system, are, as a matter of course, opposed to practical examinations. The institu- tion of the latter would necessarily cause the breaking down of the former. The truth is, there is no difficulty either in the one or the other. I have found a large class no impediment. On the contrary, it adds interest to the proceedings; and as I have never yet had to com- plain of want of decorum or absence of gentlemanly conduct on the part of my students, so I have no fear for the future. The Commis- sioners for the Universities of Scotland have enacted that the examina- tions in Medicine and Surgery shall be conducted " in part by clini- cal demonstrations in the hospital." The regulation comes into opera- tion this session (1864-65), and will, I trust, be the means of inciting you to that kind of study which, you may depend upon it, is, after all, the one best qualified to fit you for the responsible duties of the medi- cal profession. • I am satisfied that you will not cultivate practical medicine very long in this way without noticing a fact, which is every year becoming more and more evident—viz., that the art has of late years been under- going a great revolution. It is daily becoming apparent to those who observe in a spirit of sincerity and of truth, that much of the practice of our profession, which has resulted from what is called experience, is altogether incompatible with the existing state of our knowledge—that in consequence it requires a thorough revision—that the systems and nosologies of our forefathers, though useful in their day, no longer apply—and that a new field of labor is now open to the cultivation of those zealous clinical students who are anxious to identify themselves with the progress of medicine. It cannot fail to strike all those who have paid any attention to modern medical education, that whilst physiology and pathology have been making rapid advances, our previous impressions of the action of drugs, and of various modes of treatment, have become altogether changed. Whilst we were ignorant of the structure and functions of an organ or tissue, so long as we confounded together causes and results, so long we were especially apt to be led astray by tentative efforts at cure. But once that we have established on indisputable data what is really fact—what is the true law governing the progress of a disease— in how many instances does it then become evident that the means employed for its removal are feeble or altogether inert ? This has now occurred so extensively—systematic works on medicine are so at vari- ance with books on physiology and pathology—the practice of the pro- who could not practise with safety; and as long as this was the case, so long must the army medical department examine for itself. Further, " In regard to the general question of examination^ he could not consider the present system satisfactory, when it allowed men to obtain licenses who could not make a chemical examination of water, or who did not know the skeleton, or who could not put up a fractured limb or pass a catheter." POLITICAL STATE OF THE MEDICAL PROFESSION. 13 fession is so discordant with its theory—that many intellectual inquirers among us take refuge in a universal scepticism as to the action of drugs, leave everything to nature, and merely adopt what is called in France an expectant treatment, and in Germany the practice of " Nihilismus." Nay, it has been even contended that our remedies, so far from doing good, in many instances do positive injury, and that it is safer to trust to nature than to the physician. The only method of escape from this state of things, it appears to me, is by an earnest effort on the part of those who sincerely desire the improvement of our art, to establish the science of medicine upon some- thing like a solid foundation. Let us, at all events, endeavor to realise our position, and to separate what is known from what is unknown. Among the known, let us determine what we have derived from scientific generalization, and what from blind experience ; and in the vast field of the unknown, let us, if possible, agree as to the direction and manner in which we ought to work, in order to explore its extent and contract its boundaries. The propriety of this procedure is admitted. Why, then, is it not carried out ?—why cannot we co-operate in the resolve to prosecute our noble profession with a simple desire to advance it towards its true end—the cure of disease ? I will answer these questions by endeavor- ing to show what are, as I think, the circumstances which, at the outset of every honest attempt, discourage our endeavors to improve medical practice. They seem to me to be connected, as far as this country is concerned—1st, With the political; 2d, With the social; and 3d, With the practical status of our profession. On each of these subjects a vol- ume might be written, but I shall endeavor to place their leading as- pects before you in a few words. The Political State of the Medical Profession. When we regard all the other professions and pursuits of life in this great country, we find there are none of them, except medicine, whose cultivators are excluded from the high offices of state, or forbidden to aspire to any rank below that of royalty. The eminent lawyer or divine —the successful admiral or general—the popular author—or the heads of our great commercial houses, may become peers of the realm, are commonly seen taking an active part in the Legislature, and frequently receive reward or distinction, conferred upon them by a nation grateful for their services. It is a fact well calculated to excite astonishment, that a class of men who have dedicated themselves to the well-being of the public health should be comparatively neglected. In this respect we suffer with men of science in general, who, however much they may be respected individually, are but slightly encouraged by the state. The hackneyed phrase of our legislators with regard to all men of science, including medical men, is, in the words of Sir Robert Peel, that" science is its own reward; " or in the words of the Duke of Argyle, "that in the main it must depend for its advancement on its own inexhaustible attractions, and on the. delight which it affords us to study the constitu- 14 INTRODUCTION. tion of the world around us." But in every civilised country except Great Britain it has been thought a matter of good policy to encourage, by marks of honor, those who, by their scientific labors, have contri- buted to the public weal. The French reproach the profession in this country for having achieved for itself no adequate honor or reputation. It has been said that " in France, during the last half century, there is no council-board, no administration, no society, in which the medical profession has not found itself represented, whether at the court of the sovereign, or among the peerage, or in the legislature. Physicians of the Institute take their place naturally among the first of the land. Their views, their discoveries, their cures, their professional ideas and sugges- tions, must be listened to, cannot be neglected, and may never be treated as intrusion; nor had Napoleon fewer physicians and surgeons for friends, councillors, and dignitaries of state, than he had of any other profession. But in England all such interests find themselves either misrepresented, or not represented worthily; and the best of their physicians is good only to amass money, or at the highest, get a baronetcy."—(Examiner.) * All this, gentlemen, would be of little importance, did it not, as I shall point out immediately, greatly affect our social position, and through it lower the true objects for which medicine ought to be cultivated. Much of the evil arises from the fact, that the medical profession in this country possesses no national organization. Unlike the other pro- fessions, so far from there being a bond of union among its members they are irreconcilably divided by chartered medical institutions. These amount to about thirty in number, each having different powers conferred upon them by past sovereigns or governments, and an interest in ag- grandising itself at the expense of its neighbors. These various insti- tutions, though they were all established professedly to support the hon- or and dignity of medicine and its cultivators, are so discrepant in pow- er, and so conflicting in interest, that they have led to little but confu- sion and disunion among the members of the profession at large. Such, of late years, have been the clashing interests, the conflicting privileges, the injuries inflicted on the student and on medical education, the discreditable prosecutions in our courts of law of well-educated medical men, whilst the ignorant pretender is allowed to escape, and a host of other evils, that a universal cry has been raised for what is called' medical reform—that is, a re-arrangement of the affairs of the profession by an Act of the legislature. It would be curious to analyse the different measures which have been proposed for this purpose. But it was to be anticipated that our medical corporations would look after their own in- terests—oppose everything that encroached upon them—and in cases where there existed few or no privileges, that efforts would be made to obtain them, even at the expense of sister institutions. * As a public manifestation of this state of things, I may refer to the fact that, in 1858, I witnessed with pride and gratification the statue of Jenner placed in Tra- falgar Square, London, in the presence of Prince Albert, Lord Lansdowne, and other distinguished men. But I have never seen it since, as, on my next visit to the me- tropolis, it had been removed to some obscure corner—far removed from monuments to the other great men of the country. POLITICAL STATE OF THE MEDICAL PROFESSION. 15 At length, however (1858), an Act passed the Legislature which abolished the territorial privileges of the corporations, and permitted every medical man to practise, according to his qualification or qualifica- tions, throughout the kingdom. It empowered a Council to be formed of delegates from the various universities and corporations—a sort of medical parliament—which was to settle the details of, all vexed ques- tions. It ordered the preparation and publication of a Register of legally qualified practitioners, and of a national Pharmacopoeia; and provided that the licentiates and fellows of a college in one part of the country, who might desire to join another in a different part of it, might do so on the payment of a small sum (£2). In this manner the evils resulting from local privileges and jurisdiction were to a great extent removed. Other disputed points as to the nature of qualifications, what should constitute a national and uniform medical education, instead of the vexatious curricula of so many medical boards, and a variety of im- portant but minor considerations, were to be determined by this Medi- cal Council. Since the Act has become law, a Register of qualified practitioners, for the information of the public, and having absolute authority in courts of law, and a national Pharmacopoeia, have been published; but as to the other points we have still to wait for further deliberations of the Council. While these efforts to regulate the medical profession, or what has been called Medical Reform, were proceeding, other attempts were being made to extend and improve the advantages of our national Universities, or what has been called University Reform. It became generally felt that the system sanctioned by long usage in these ancient institutions required modification to meet the altered demands of the times; that the great end of all education was not to acquire abstract learning or science, but to render knowledge useful in life ; and that the value of that education ought to be tested by its fitness to prepare men for the various professions and administrative offices of the country. It was maintained that a university education, therefore, should make not merely a learned man, but also a practical man, and that academical de- grees should not be regarded only as marks of honor—to be crowned, as in the Olympian games, with chaplets of barren leaves—but should be considered as proofs of proficiency, and rewarded with branches on which, like those from the garden of the Hesperides, we might look for golden fruit. In short, the spirit of our time, and the most obvious good policy, pointed to the support and extension of the Universities as the true source of professional knowledge for the youth of our country. It is there that intimacies are formed between men of different classes and professions; it is there that the narrow tone of mind, fostered by mere professional schools, is counteracted; it is there that the associated students learn the value of general information and enlarged ideas when brought to bear upon distinct pursuits; and it is there that the preju- dices of caste and of corporate exclusiveness are merged in the catholic desire to render education as general as possible for the good of the country at large. Great changes, in consequence, have been gradually made in the government and regulations of the English and Irish Universities. A new University was established in London, a second in 16 INTRODUCTION. Durham, and another with three colleges in different cities of Ireland, each having a complete medical faculty. And, lastly, the Scottish Uni- versities have been made the subject of an Act of Parliament, whereby, as you are aware, this University obtained a new constitution, which is now in full operation, and which gives students, graduates, and profes- sors a share in its government. It would be evidently premature to speak of what is likely to be the result of all this legislation with regard to the welfare of the medi- cal profession. But already events have taken place with which, as ma- terially influencing your future position, you should be acquainted. The Medical Act provides that two or more corporations may unite for the purpose of constituting one examining board, and thereby securing at once an efficient examination in two or more of their especial depart- ments—the successful candidate receiving the licenses of the different corporations who so unite. This plan, if conscientiously carried out, cannot but be of the greatest service, and, without depriving these bodies of their privileges, abolishes one of the great evils to which I have pre- viously alluded. Thus in England, a union of the Colleges of Physicians and Surgeons would enable those distinguished bodies to appoint able physicians and surgeons in every way qualified to carry put the important duties of examiners, and what seem to be the purposes of the Act. Such would appear to be the reason why the English Poor- law and Army Medical Boards insisted that their medical officers, who are required to practice both medicine and surgery, should possess what is called the double qualification. In other words, they demand to be satisfied that such candidates have been carefully examined in medicine by physicians, and in surgery by surgeons, which is obviously the only way of ensuring that the examination has been a bona fide one. But in Scotland, the fellows of the Royal Colleges of Physicians and Surgeons are, with few exceptions, parties who practise both branches of the art, and are what is called in. the profession general practitioners. There is, in truth, little distinction between the one college and the other; so that, in forming a joint board, unless the few physicians on the one side, and the few surgeons on the other, constituted that board, there would be no guarantee of a thorough medical and surgical exami- nation, as would occur in the case I have supposed of the London Colleges. Instead of different elements being united to make a perfect whole, similar elements are brought together from the two institutions, neither medicine nor surgery being properly represented at all as dis- tinct professions. Such a plan does not fulfil the object of the Medical Act, nor meet the requirements of the Poor-law and Army Medical Boards. While these powers were given by the Medical Act to the numerous corporations, the ancient large privileges granted to the Universities were confirmed. The Universities can now grant the degrees of Doctor, Bachelor, or Licentiate of Medicine, and Master of Surgery; and their graduates, on presenting their diplomas, are enrolled in the General Register of Medical Practitioners, and are empowered to practise both in medicine and surgery, as has been the practice immemorially among the great Continental Universities. There can be no doubt that the adoption POLITICAL STATE OF THE MEDICAL PROFESSION. 17 of this course generally would be of great advantage to the public and to the profession at large. It would not only elevate the status of sur- geons, by conferring upon them academical rank, but would constitute another means of getting rid of those corporate distinctions which have created so much jealousy among medical men. The necessity of extending the preliminary studies has met with the concurrence of all parties. The conviction has gained ground, that he who wishes to understand the phenomena of the animal economy must approach them by the way of a logical and physical, as well as by that ox a classical education. In future, therefore, no one can enter upon the study of medicine until his knowledge in lite- rature and arts has been more satisfactorily tested than it was former- ly. The regulations on this head, it is hoped, will tend to enlarge the attainments of medical students, and produce a favorable reaction on medicine itself. I must not overlook the circumstance, that it has already become necessary to repeal an important clause in the Medical Act, in conse- quence of an occurrence which was not anticipated. This consisted in the Royal College of Physicians of Edinburgh selling its licenses to the surgeons, apothecaries, and druggists of England, without examination, for the sum of £10 ; while many of the purchasers, to the astonishment of the profession, assumed in consequence the university title of Doctor of Medicine, wThich the College in question had taken no steps to prevent. I shall not venture to state any opinion of my own as to this unfortunate transaction, but give you that of an eminent physician, himself a Fellow of the College he complains of, and who spoke as follows when President of the British Medical Association : " It is to be hoped," he sdys, " that the self-respect of our profession will deter its members from supporting this sale of medical indulgences, and so, by rendering the English traffic less lucrative than was anticipated, lead its promoters to remember the purpose for which their College was established. A distinction in letters, whether in medicine, law, or divinity, which maybe obtained by merely paying down a few pounds, is worth precisely what it costs ; it proves pecuniary ability, nothing more. The initials of physician by purchase would correctly intimate the estimation in which the possessor of such a distinction will be held by every one but himself. There is a want of more of acknowledged authority in our profession, and not of less. And although colleges may have but little power to create this, they are not, as in this instance, without the power to lessen that which exiits. I feel personally," continues Dr. Radcliffe Hall, " that faith is not kept with those who formerly considered it creditable to be connec- ted with the Edinburgh College of Physicians; and that, in bare jus- tice, every Fellow ought to have a vote in deciding whether or not so radical a degradation of his College should take place. Surely there is great defect in the constitution of the Medical Council of Great Britain if it cannot interfere to prevent so grave an abuse of vested authority as this."* *Address to the South-Western Branch of the British Medical Association. Brit. Med. Jour., July 9, 1859. 2 IS INTRODUCTION. Gentlemen, the Medical Council did interfere, and insisted on a med- ical examination; but how far this was rendered stringent we will not inquire. No less than 356 candidates passed this so-called ex- amination between the 29th March and 20th April of 1860; and during twelve months, nearly 1000 persons altogether obtained the license. The result has been, that the London College of Physicians, having first remonstrated in vain, properly refused to admit this flood of licentiates to its own body on the conditions provided by the Act; and the clause which enabled a medical man on changing his residence to join a sister college at a nominal charge, has been repealed in a short bill, which, under the circumstances, all parties admit to be necessary. Thus, not only has the status of physic and physicians been lowered in Scotland by the institution expressly founded to elevate both, but all fellows and licentiates of every college in the kingdom have, by its conduct, been excluded from an important reciprocal privilege, which had been long struggled for, and which was actually conferred upon them by the Legislature. As young graduates, you will naturally feel indignant that the title of Doctor should be usurped by parties who have no claim to it. Such, however, is the difficulty of legislating on this matter, and so indiscrimi- nate the manner in which the highest medical title is given by the public, that I have no other advice to offer you than this,—viz., that on all proper occasions you should at least do yourselves the justice of pointing out the distinction (not apparently understood in England and abroad) be- tween the College of Physicians and the University of this city. I sin- cerely trust that the Royal College before long may see it to be consist- ent with its honor to repudiate an act which has been so universally con- demned by the profession at large. Such then, is the actual political condition of the profession into which you are about to enter. Let us hope that, as the Medical and Scotch Universities Acts are brought into operation, the cause of medical education, and the improvement of the schools, will advance. Among these, that of Edinburgh has hitherto occupied a prOud position; and great indeed will be the responsibility of those who, with the power of supporting and increasing her influence, are induced to cripple her re- sources and impede her usefulness in the vain hope of reconciling inter- ests and satisfying institutions which are essentially antagonistic. What we require is a legislation which, instead of maintaining a system of rival institutions and opposing schools, perpetuating disunion and re- tarding the cause of scientific progress among us, will draw these dis- cordant elements together, for the purpose of co-operation and mutual support. Nor is this impracticable, as such a constitution exists in most Continental nations, and has been found to work admirably. To this end the various universities and corporations, instead of independent and contradictory action, should be empowered to carry out one system of education and privilege in the three divisions of the kingdom, subordi- nate to a uniform direction. Instead of numerous schools acting as rivals to and injuring one another, a machinery ought to be devised by which the talent now diffused and wasted should be concentrated under THE SOCIAL STATE OF THE MEDICAL PROFESSION. 19 a wise administration, so as to strengthen instead of weaken our national Universities. In this manner the strongest stimulus would be given to successful exertion, while ability and scientific merit might hope to meet something like adequate reward. Gentlemen, believing that the interests of medicine as a science, its dignity as a profession, and its usefulness to the community, are inti- mately associated with the manner in which public bodies carry out the spirit of their foundation statutes and charters, you will not, I trust, re- gard my having directed your attention to this important subject as un- necessary or inopportune, To explain fully the numerous intricacies of this perplexed matter time would not permit. I shall be satisfied if, on reflection, my remarks shall have led you to see the incongruity in a science like medicine, which is one and indivisible, of its cultivators being constantly opposed to one another on account of corporate distinc- tions and animosities. I would earnestly urge you to labor in the cause of union—which, proverbially, is strength—as the only method of placing the profession of medicine in a dignified position with regard to the State on the one hand, and the public on the other, and thus furthering the beneficent object for which it is cultivated. The Social State of the Medhal Profession. The evils resulting from the political condition of the medical pro- fession have led to still greater ones in its social state. In consequence of the complete absence of public positions, with emoluments sufficient to satisfy the reasonable desire and ambition of scientific men—as the most skilful physician, or most successful discoverer, does noti, in conse- quence, receive any dignity or honor from the State—and as the offices of our medical corporations as they are at present managed are utterly incapable of supplying the deficiency—it follows that the only prize open to the aspiring and ambitious is the wealth to be derived from an enormous practice. If, indeed, there were any necessary relation between the popularity of a physician and his real professional merit, we might recognise thi.s as, so far, a reward and encouragement. But it is notorious that this is not the case, and that in many instances large practices are acquired by the most unblushing charlatanism. St. John Long was supposed to have received about twelve thousand pounds a year for pretending to cure consumption by rubbing an escharotic liniment into the chest, and when at length he was tried for the manslaughter of Miss Cashin, evidence in his favor was given by half the aristocracy of the metropo- lis. In all ages, indeed, the successful pretender has succeeded in col- lecting more gold than could be accomplished by honorable members of the profession; formerly, however, the imposture was manifest, and car- ried its own shame with it. But the bane of the profession at this mo- ment is the existence of a class of medical practioners who, in arduous competition with their fellows, and pressed, perhaps, by the necessity, if not the desire, of making money, have come to the conclusion, that what they really know and can perform professionally is of much less 20 INTRODUCTION. consequence than what the public gives them credit for. The ultimate influence of this state of things on their own morals, and on the welfare of the profession, must be obvious. But let us suppose that a really able man, after years of toil and anxiety, at length reaches the full career of a metropolitan practice. Is this, after all, a suitable reward for his labors ? Is this position really a desirable one, with regard to its results either on his own mind or on the honor and higher interests of his profession ? On this head I pre- fer reading the statement of another. "Many years' attention to all subjects affecting the profession of physic," says an anonymous writer, " has led us to the conclusion that large practices, the only prizes which the profession offers at present to its members, are in many ways its bane. By them the high scientific tone of the profession is depressed; its independence sunk; a low standard of effort is fostered; the indi- vidual who succeeds is rendered worthless; the public cheated ; false practice authorised; quackery promoted ; and sterling merit often de- prived of its just reward."* The same writer goes on to observe that occasionally also, this ex- cessive practice leads to such a love of money, or desire to be thought important, distinguished, or influential, that in order to obtain it, the proper etiquette of the profession is abandoned, and every feeling of gentlemanly propriety and honor is first blunted, then destroyed. The great position a person of this kind fancies he has attained leads him to overlook the interests and just claims of his fellow-practitioners, and to tempt away their patients, who, after all, among the crowd of those he attends, are often sadly neglected. By watching the progress, and mingling in the society of certain men of this class, the professional mind is in. danger of being Tendered unsound, and actuated more by a desire of attaining what is conventionally received as " success in life"— which simply means the obtaining of a large income—than by the higher incentive of public usefulness. The Present State of Practical Medicine. If the political state of the medical profession leads to the deteriora- tion of the social one, so does the latter lead to the greatest confusion id, and distrust cf, the power of cure. What, indeed, is to be expected of men whose highest aim and boast are to have a large practice? Are the statements of their wonderful cures, of their practical knowledge, and the success of remedies in their hands, and so on, to be trusted— statements which, for the most part, so far from promoting, tend only to retard and obstruct the advancement of the medical art? On the other hand, those of this class who act conscientiously (and many such, to the honor of medicine, exist) are too busy in the active duties of their call- ing, and have too little time to follow the rapid progress of the science. Hence, what they have acquired by long experience is seldom seen by * Azygos on Medical Reform, London, 1853. The author of this pamphlet will sec that I have adopted some of his arguments and a little of his phraseology. PRESENT STATE OF PRACTICAL MEDICINE. 21 them to harmonise (though truth in practice always must in the end har- monise) with truth in theory. Although twenty-four years have elapsed since the cell doctrine of growth has been admitted into physiology and pathology, medical men have not yet realised to themselves its vast importance in a practical point of view. The morbid processes of inflammation, of tuberculiza- tion, and of various morbid growths, are now for the most part elucidated by this theory. But a cell pathology is no more universally applicable to the phenomena of disease than is humoralism or solidism. Indeed, we may more correctly speak of a molecular pathology, for a molecule, and not a cell, is the first and last form of organisation. What, however, it is important to remember here is, that if there be a molecular or a cell physiology and pathology, so there is a molecular and a cell therapeutics. For it is evident that those diseases which depend on an increase or di- minution of molecules and cells can only be reached scientifically through a knowledge of those laws which govern their evolution and disinte- gration. Thus, growth (that is, the multiplication of cells) is favored by in- creased warmth, by room for expansion, and by moisture ; and it is checked by cold, by pressure, and by dryness. If, then, an exudation be poured out and coagulated near the surface, as it can only disappear by its passing through the stages of cell growth, we favor suppuration—that is, the growth of pus-cells—by warm poultices or fomentations, and re- tard it by cold and pressure. Pneumonia consists of an exudation into the vesicles and tissues of the lung, which coagulates and excludes the air. It is very doubtful whether a large bleeding from the arm can operate upon the stagnant blood in the inflamed part, or the congested capillaries in its neighbor- hood; that it can directly affect the coagulated exudation is impossible. But by lowering the strength and vital power of the individual, venesec- tion is directly opposed to the necessary vital changes which the exuda- tion must undergo in order to be removed by cell growth and disintegra- tion. Hence it is, in my opinion, that the mortality from pneumonia has diminished since large bleedings have been abandoned, and not because, as has been suggested by an eminent authority, inflammations, like fevers, have changed their types since the days of Cullen and Gregory. The absorption of a pleuritic effusion depends on the formation of new blood-vessels in the coagulated exudation which is adherent to the pleurae. These in their turn are the results of cell formation. Such formation so far from being encouraged, can only be retarded or pre- vented by large bleedings and antiphlogistics. The growth of tumors may be encouraged or retarded by the same means which influence all other kinds of cell development. But if they assume a parasitic character, "as in cancerous growths—that is, if the cells possess a power of multiplication in themselves—then the only chance of cure is in their complete destruction or extirpation. But the surgeon who trusts to his naked sight, forgets that germs are infiltrated among the surrounding tissues, and are so minute that he cannot see them; yet he employs no microscope to discover them. He cuts out a tumor, but only cuts through the disease. Need we winder, therefore, that cancer 22 INTRODUCTION. should frequently return, or rather continue to grow, when in fact it had never been removed ? Our improved knowledge with regard to parasites, both animal and vegetable, illustrates the flood of light which the cultivation of natural science has thrown upon diseases, the pathology of which was formerly unknown. It has now been shown that an animal may live as a cystic worm in one animal—say a mouse, and as a tapeworm in another— say a cat; and that to prevent the appearance of the last parasite, we must not allow the former one to enter the digestive organs as food. In like manner, the demonstration that favus, pityriasis, diphtheria, pyrosis, and other disorders are connected with the growth of vege- table organisms, has completely revolutionised the treatment of those affections. The beneficial changes which have taken place in our treatment of apoplexy, syphilis, small pox, phthisis, Bright's disease, and many other diseases, might in like manner be shown either to have originated from or to be capable of being satisfactorily explained by an advanced know- ledge of physiology. Again, notwithstanding the universality with which the stethoscope and auscultation are now received as necessary means of diagnosis, how few of our medical men, comparatively, are really skilful in detecting by them the morbid changes going on in the heart and lungs. The stetho- scope, indeed, was as much sneered at when it was first introduced as was the microscope. Physicians existed who taught that a piece of stick was not likely to make us discern what was going on in the lungs, and who cautioned students against losing their time in learning auscultation, just as some now do in reference to histology. But the philosophic practitioner must see the necessity of using every means in his power for detecting disease, whether stethoseopical, microscopical, or chemical. I cannot too strongly advise you not to be influenced by the opinion of those who, educated before these means of research came into general use, speak of them as worthless, especially in the investigation and diag- nosis of disease. It is because they are ignorant of their value that they hold them out as of little benefit. I need scarcely remark that this kind of reasoning is altogether unsound, and is directly opposed to the intro- duction of all improvement in either science or art. What should we think of a modern astronomer who sneered at teleseopes, and boasted that it was enough for him to examine the heavens with his naked eye ? or how should we like to trust ourselves at sea with the navigator who, as in ancient times, steered by the sun and stars, and who abused sextants and other instruments by which alone exact calculations can be made of his course ? Such, however, is precisely what those medical men do who underrate stethoscopes and microscopes, betraying an unacquaintance with the present state of their own art. At all events, in this Clinic, you will find that we seize eagerly on every means that science places in our hands for detecting the true nature of disease ; that percussion, auscultation, histology, and chemistry are all pressed into our service; that, whilst we spare no pains to make ourselves masters of observation, cultivate our senses to the utmost study PRESENT STATE OF PRACTICAL MEDICINE. 23 symptoms, and thus endeavor to unite the knowledge of the present day with the experience of the past; we never forget that the Medical Art is founded on science, the only guarantee of its elevated and ennobling character, and the only secure means for its future advancement. What, then, is required, in the present condition of medicine, is an attempt to bring our advanced knowledge of physiology and pathology to bear upon the treatment of disease, and by renewed observation, with all the aids which modern diagnosis gives us, to reinvestigate the action of our more important remedies. In so doing, we should not neglect past experience, but endeavor to make the truths it has taught us har- monise with scientific laws. So far from believing in the propriety of a pure expectant system or a " Nihilismus," I am convinced that experience has furnished us with some most precious results. No one can doubt, for instance, that quinine cures ague, and that lemon-juice cures scurvy. Why they do so we are ignorant; and hence those remedies are given empirically— that is, as a result of blind experience. It has also been distinctly shown that sulphur ointment cures scabies. But here, I think, false reasoning has stepped in, and declared sulphur to be as much a specific for scabies as quinine is for ague. But scabies depends upon the presence of insects which lay their eggs in the skin; and the greasy matter of the ointment is brought, by means of friction, into contact with, and asphyxiates them, just as well without as with sulphur. But to dis- cover these insects, and to determine their habits, patient and long-con- tinued scientific research was necessary, and practice now reaps the bene- fit of it. It is true that the contradictory opinions concerning medical doctrine and practice have, in all times, excited the ridicule of the weak-minded, and still constitute the ground on which Medicine is attacked by the ignorant and superficial. Yet the differences which exist no more prove that there is no foundation for Medicine as a science, than the varieties of religious sects show that there is no truth in religion, or than the opposing dicisions of our courts of law prove jurisprudence to be a farce. All these contradictions depend upon imperfect attempts at cor- rect theory; and this latter once rendered perfect, it will be seen that both health and disease are governed by laws as determinate as the motion of the planets and the currents of the ocean. But notwithstanding the discouragements which knowledge has re- ceived and will ever suffer from the indolent or narrow-minded, at no period has the tendency to cultivate scientific medicine been more strongly manifested than it is at this moment. Everywhere in Europe do we observe a noble effort to enlarge the foundations on which its practice is based. Everywhere we see Natural Philosophy advancing; enthusiastic chemists pushing forward organic analyses; anatomists unwearied in their researches concerning development and the structure of tissues; physiologists experimenting and concentrating all the re- sources of modern science in order to elucidate organic laws ; and patho- logists busy in connecting the symptoms observed in the living, with alterations in the minutest tissues and atoms of the dead. At this time Medicine is undergoing a great revolution, and to you gentlemen, to the 24 INTRODUCTION. rising generation, do we look as to the agents who will accomplish it. Amidst the wreck of ancient systems, and the approaching downfall of empirical practice, you will, I trust, adhere to that plan of medical education which is based on Anatomy and Physiology. If you resolve to follow in the legitimate path of improvement to which all reason and experience invite you, be assured that the toil of mastering what is now known of correct generalization will not be in vain. Everything pro- mises that before long a law of true harmony will be formed out of the discordant materials which surround us ; and if we, your predecessors, have failed, to you, I trust, will belong the honor of building up a system of Medicine which, from its consistency, simplicity, and truth, may, at the same time, attract the confidence of the public, and command the respect of the scientific world. SECTION I. EXAMINATION OF THE PATIENT. It is absolutely necessary that an examination of patients at the bed-side should be conducted with order, and according to a well-understood plan. I have observed that some students, on being called upon, in their turn, to interrogate a case, feel great embarrassment, and are unable to proceed. Others put their questions, as it were, at random, without any apparent object, and wander from one system of the economy to another, vainly searching for a precise diagnosis, and a rational indication of cure. But continual practice, and the adoption of a certain method, will remove all difficulty. No doubt, questioning a patient, to arrive at a knowledge of his condition, requires as much skill in the medical practitioner, as ex- amining a witness does in counsel at the bar. They make it an especial study, and you must do so likewise. You should remember that, in proportion as this duty is performed well or ill, is the probability of your opinion of the case being correct or incorrect; and not only will the re- putation you hold among your colleagues greatly depend on your ability in this matter, but the public also will promptly give its confidence to him whose interrogations reveal sagacity and talent. The method of examination differs greatly among practitioners, and must necessarily vary in particular cases. Men of experience gradually form a certain plan of their own, which enables them to arrive at their object more rapidly and securely than that adopted, with perhaps an equally good result, by others. In a clinical class, however, and in order that every one present may follow and understand what is going forward, the method adopted must be uniform. I hold it to be a matter of great importance, that every one standing round the bed should take an equal interest in what is proceeding, and this he cannot do unless he is fully aware of the manner and object of the examination. The plan which appears to me the best, and which we shall follow, is the one I learnt when myself a clinical student in the wards of Professor Rostan of Paris. Its object is to arrive, as quickly as possible, at a knowledge of the ex- isting condition of the patient, in a way that will insure the examiner that no important organ has been overlooked or has escaped notice. For this purpose, we search out, in the first instance, the organ principally affected, and ascertain the duration of the disease, by asking two questions, " Where do you feel pain ?" and, " How long have you been ill ? " Let us suppose that the patient feels pain in the cardiac region, 26 EXAMINATION OF THE PATIENT. we immediately proceed to examine the heart functionally and physically, and then the circulatory system generally. We next proceed to those organs which usually bear the nearest relation to the one principally affected—say, the respiratory organs—and we then examine the lungs functionally and physically. We subsequently interrogate the nervous, digestive, genito-urinary, and integumentary systems. It is a matter of little importance in what order these are examined—the chief point is, not to neglect any of them. Lastly we inquire into the past history of the case, and thus we arrive at all the information necessary for the for- mation of a diagnosis. The following is the arrangement of symptoms and circumstances demanding attention under each of the seven heads into which the ex- amination is divided:— I. Circulatory System—Heart.—Uneasiness or pain; its action and rhythm ; situation where the apex beats ; extent of dulness deter- mined by percussion; its impulse; murmurs—if abnormal, their character, and the position and direction in which they are heard loudest. Arterial pulse—Number of beats in a minute; large or small, strong or feeble, hard or soft, equal or unequal, regular or irregular, intermittent, con- fused, imperceptible, etc. If an aneurismal swelling exist, its situation, pulsations, symptoms, extent, and sounds,' must be carefully examined. Venous pulse—If perceptible, observe position, force, etc. II. Respiratory System.—Nares.->—Discharges; sneezing. Larynx and Trachea—Voice, natural or altered in quality, hoarse, difficulty of speech, aphonia, etc.; if affected, observe condition of epiglottis, tonsils, and pharynx, by means of a spatula. Lungs— State of respiration; easy or difficult, quick or slow, equal or unequal, labored, painful, spasmodic, dyspnoea, etc.; odor of breath. Expectoration, trifling or profuse, easy or difficult; its character, thin or inspissated, frothy, mucous, purulent or muco-purulent, rusty, bloody ; microscopical exami- nation. Hasmoptysis, color, appearance, and amount of blood discharged. Cough, rare or frequent, short or long, painful or not, moist or dry. External form of the chest, unusually rounded or flattened, symmetrical or not, etc. Movements—regular, equal, their amount, etc. Resonance, as determined by percussion, increased or diminished, dulness, cracked- pot sound, etc. Sounds determined by auscultation, if abnormal, their character and position. III. Nervous System. — Brain — Intelligence—augmented, per- verted, or diminished ; cephalalgia ; hallucinations ; delirium, stupidity, monomania, idiocy; sleep, dreams, vertigo, stupor, ccma. Spinal cord and nerves—Fain m back; general sensibility, increased, diminished or absent; special sensibility—sight, hearing, smell, taste, touch, their increase, perversion, or diminution ; spinal irritation, as determined bv percussion; motion, natural or perverted, fatigue, pain on movement, gait; trembling, convulsions, contractions, rigidity, paralysis. IV. Digestive System.—Mouth—Lips, teeth, and gums • taste in the mouth, saliva. Tongue—Mode of protrusion, color, furred, coated, fissured, EXAMINATION OF THE PATIENT. 27 condition of papillae, moist or dry. Fauces, tonsils, pharynx, and esopha- gus—Deglutition—if impeded, examine the pharynx with a spatula ; the cervical glands, neck, etc. ; regurgitation. Stomach—Appetite, thirst, epigastric uneasiness or pain, swelling, nausea, vomiting, character of matters vomited, flatulence, eructations. Abdomen—Its measurement and palpation; pain, distension or collapse, borborygmi, tumors, constipation, diarrhoea, character of dejections, haemorrhoids. Liver—Size, as determin- ed by percussion, pain, jaundice, results of palpation, etc. Spleen—Size, as determined by percussion. If enlarged, examine blood microscopically. V. Genito-Urinary System.— Uterus—Condition of menstrual dis- charge, amenorrhoea, dysmenorrhcea, menorrhagia, leucorrhcea, etc. If there be long-continued pain, or much leucorrhoeal discharge, examine os and cervix uteri with the finger, and, if necessary, with the speculum; uterine or ovarian tumors; pain in back; difficulty in walking, or^ in defsecation; functions of mammse. Kidney—Lumbar pain; micturition; quantity and quality of urine, color, specific gravity; tube casts and precipitates, as determined by the microscope, and by chemical tests; ac- tion of heat; nitric acid, etc.; action on test papers ; stricture; discharges from urethra ; spermatorrhoea; etc. (See use of Chemical Tests.) VI. Integumentary System!—General posture; external surface; color ; expression of countenance ; hue of lips; obesity ; emaciation ; rough or smooth; dry or moist; perspiration; marks or cicatrices; eruptions (see diagnosis of skin diseases) ; temperature ; morbid growths or swelling; anasarca; oedema; emphysema, etc. VII. Antecedent History.—Age; parentage ; constitution ; here- ditary disposition; trade or profession; place of residence; mode of living as regards food and drink; habits; epidemics and endemics; contagion and infection; exposure to heat, cold, or moisture ; kind of lodging, drainage, water, smells, etc.; irregularities in diet; excesses of any kind; fatigue ; commencement and progress of the disease; date of rigor or seizure ; mode of invasion ; previous treatment; in female cases whether married or single—have had children and miscarriages—pre- vious diseases, etc. Such are the principal points to which your attention should be directed during the examination of a case. A little practice will soon impress them on your memory, and in this manner habit will insure you that no very important circumstance has been overlooked. At first, in- deed, it may appear to you that such a minute examination is unneces- sary ; but we shall have abundant opportunities of proving that, whilst a little extra trouble never does harm, ignorance of a fact frequently leads to error. It is surprising, also, how rapidly one thoroughly con- versant with the plan, is able to examine a patient so as to satisfy him- self that all the organs and functions have been carefully interrogated. Remember that the importance of particular s}rmptoms is not known to the patient, and that, consequently, it is not in his power voluntarily to inform you of the necessary particulars. It is always your duty to dis- cover them. 28 EXAMINATION OF THE PATIENT. In carrying out the examination, the following hints may be attended to: 1. It should never be forgotten that you are examining a fellow- creature who possesses the same sensitiveness to pain, and the same feelings that you do, and that everything that can increase the one and wound the other should be most carefully avoided. Prudence, kindness, and delicacy, are especially enjoined upon those who treat the sick, and no levity ought to be tolerated among those who are determining the value and duration of life. 2. The questions should be precise, simple, and readily compre- hended. When an individual has a limited intelligence, or is accus- tomed to a particular dialect, you will not arrive at your object by becoming impatient, or talking in a loud voice, but by putting your interrogations in a clear manner, and in language proportioned to the intelligence of the individual. 3. It is often necessary, after asking the first question, " Where do you feel pain ? " to tell the patient to put his or her hand on the part. An Irish peasant applies the term " heart" to an indefinite region, extending over great part of the chest and abdomen; and a woman, in speaking of pain in the stomach, often means the lower part of the abdomen. 4. When pain is referred to any circumscribed part of the surface, the place should always be examined by palpation, and, if possible, seen. Rostan relates very instructive cases where the omission of one or the other of these rules has led to curious errors in diagnosis. 5. Although the question, "How long have you been ill?'" is sufficiently plain, it is often difficult to determine the period of com- mencement of many diseases. In acute inflammatory or febrile disorders, we generally count from the first rigor. In chronic affections, a length- ened cross-examination is frequently necessary to arrive at the truth. 6. A state of fever may be said to exist when we find the pulse accelerated, the skin hot, the tongue furred, unusual thirst, and headache. These symptoms are commonly preceded by a period of indisposition, varying in duration, and ushered in by a rigor or sensation of cold. Such a febrile state may be idiopathic, when the case is called one of fever, or symptomatic of some local disease, when the nature of the case is determined by the organ affected and lesion present. 7. During the physical examination of a case, the temperature of the apartment should be considered, and the doors and windows shut, so that the patient be guarded against cold. For the same reason exposure of the surface should not be continued longer than is necessary. Silence must be maintained not only amongst those who surround the bed, but generally throughout the ward. When the patient is weak the physical examination should be shortened, or altogether suspended. 8. In endeavoring to ascertain the cause of the disease, great tact and skill in examination are necessary. We must guard ourselves against the preconceived views of the patient on the one hand, and be alive to the possibility of imposition on the other. Sometimes, with all our endeavors, no appreciable cause can be discovered; and at others we find a variety of circumstances, any one of which would be sufficient to occasion the malady. 9. In forming our diagnosis—that is, in framing a theory deduced EXAMINATION OF THE PATIENT. 29 from the facts elicited by examination—we should be guided by all the circumstances of the case, and be very careful that these are fully known before we hazard an opinion. Even then it is not always possible to come to a satisfactory conclusion, and in such cases the diagnosis should be deferred until further observation has thrown new light upon the nature of the disease. 10. In recording a case, it is, for the most part, only necessary to put down, under each head, the symptoms or signs present. If any system be quite healthy, it should be said that it is normal. In many cases, however, it is necessary to state what are called negative symptoms. This demands great tact, and exhibits a high degree of medical informa- tion. For instance, an attack of epilepsy generally commences with a cry or scream; but sometimes there is none—when this should be stated. Again, no expectoration is a rare negative symptom in pneu- monia. Symptoms which are usually present in the disease, but are absent in the particular case, constitute negative symptoms. 11. All mention of size should be according to its exact measurement in feet and inches. Situation is often referred to certain regions, into which the surface has been arbitrarily divided, such as subscapular, cardiac, epigastric, etc., but it is always better to refer at once to anato- mical parts, such as the clavicle, particular rib, nipple, umbilicus, angle of scapula, and so on. Extent should also be determined by proximity to well-known fixed points. All vague statements, such as large, great, small, little, etc., should be carefully avoided. It is useless to speak of the pulse or of the respiration as being quick or slow, whereas by saying that the first is 60 or 120, and the second 12 or 40 in the minute, a correct statement is given at once. In recording cases, dates and references should always be stated in the day of the month, or still better, of the disease,and not in the day of the week. The authority formany statements should be given; such as, the patient, the nurse, or the friends, say, etc. 12. In conversing on, or discussing, the circumstances of the case at the bed-side, we should always use technical language. Thus instead of saying a man has a cavern at the top of the lung, we should speak of a vomica under the clavicle; instead of saying a man has a diseased heart we should speak of cardiac hypertrophy, or of insufficiency of the mitral or aortic valves, etc. In a witness-box, before a jury, it is right to use the common familiar names of things, and instead of cranium to say skull, instead of axilla to say arm-pit, instead of abdomen to say belly, etc. There, the object is to instruct the uneducated ; here, the educated in medicine, while, at the same time, we avoid alarming or causing anxiety to the patient. 13. In prescribing for the patient, many circumstances should be taken into consideration, such as, the probable time of your next visit, the form in which medicine is most easily taken by the patient, his means, etc. The prescription should be written in Latin, and the quantities denoted by the usual pharmaceutical signs, but the directions tor administration should be written in English. Having formed a diagnosis, and prescribed for the patient, the further examination should be conducted at intervals, varying, as regards time, according to the gravity of the case. In addition to the changes 80 EXAMINATION OF THE PATIENT. which may occur in the signs and symptoms previously noticed, the effect of remedies should be carefully inquired into, and care taken to ascertain whether the medicine and diet ordered have been administered. If the case prove fatal the symptoms ushering in death, and the manner in which it occurs, should be especially observed. Whenever a record of the case is to be kept, I cannot too strongly impress upon you the importance of noting these down in a book at the time, rather than trusting to the memory.* For a long series of years the reports of cases, dictated aloud by the professor, and written down at the bed-side by the clerk, has formed a leading feature of the Edinburgh system of clinical instruction, and constitutes the only trustworthy method of drawing up cases with accuracy. When a patient dies, the examination is not completed. The time has now arrived when an inspection of the dead body confirms or nulli- fies the diagnosis of the observer. You should consider this as a most important part of the clinical course. It is invariably regarded with the greatest interest by those who practise their profession with skill. It is only in this manner that any errors they may have committed can be corrected; that the value of physical diagnosis can be demonstrated and properly appreciated, and the true nature or pathology of diseases, and the mode of treating them rationally, can ever be discovered. But here, again, method and order are as necessary in the examina- tion of the dead as of the living, and it is of equal importance that no viscus be overlooked. The three great cavities should always be inves- tigated. Nothing is more injurious to the scientific progress of medicine than the habit of inspecting only one of them, to satisfy the curiosity of the practitioner or to determine his doubts on this or that point. Many medical men direct their attention to a certain class of diseases, and are apt to attribute too much importance to a particular lesion. It has frequently happened to me, when pathologist to the Royal Infirmary, to observe, that after the physician has examined this or that organ, to which he has attributed the death of his patient, and left the theatre, that after examination, according to the routine I always practised, has revealed important lesions that were never suspected. Thus a person supposed to die of Bright's disease of the kidney, may have a pneumonia that was latent and overlooked. Large caverns and tubercular deposits in the lungs may satisfy the physician, and he may leave the body when intense peritonitis may be subsequently found, arising from intestinal perforation. A man has hypertrophy, with valvular disease of the heart; he dies suddenly, and everything is referred to the cardiac lesion. On opening the head, an apoplectic extravasation or yellow softening may be discovered. I cannot too strongly, therefore, impress upon you the ne- cessity of always making a thorough post-mortem examination, and for this purpose you should, if possible, obtain permission to inspect the body and not any particular cavity. The object of a post-mortem examination is threefold :__1st, The * I have arranged a note-book for taking cases, according to the system of exami- nation here recommended, which may be procured of Mr. Thin, medical book-seller close to the Infirmary. EXAMINATION OF THE PATIENT. 31 cause of death; 2d, An appreciation of the signs and symptoms; 3d, The nature of the disease. These inquiries are very distinct, but practitioners generally have only in view the two first. It frequently happens that, on the discovery of a lesion that seems to explaio. the fatal termination, they feel satisfied, and there is an end to the investigation. In medico- legal cases, this is the only object. But even here it is necessary to examine all the organs, to avoid a possibility of error, for how can any conscientious man form an opinion, that an abdominal disease has been fatal, if he be not satisfied by inspection that the chest and brain are healthy ? Again, it often occurs that a particular sign or symptom is unusual or mysterious, and this, if explained by the examination, is sufficient for the practitioner. But it must be obvious, that this throws no light upon the nature of the disease, or its mode of cure. To do this, morbid changes must be sought for, not in that advanced stage where they cause death, or occasion prominent symptoms, but at the very earliest period that can be detected. Hence we must call in the micro- scope to our assistance, and with its aid follow the lesion into the ultimate tissue of organs; we must observe the circumstances which produced it, as well as the symptoms and physical signs to which it gives rise; the secondary disorders, and the order of their sequence; their duration and mode of termination. This is the kind of extended investigation which can alone be serviceable to the advancement of medicine, and such, I trust, will be the object you will have in view in examining dead bodies. At all events, such are the views that I shall constantly endeavor to place before you during this course of clinical instruction. The following is an arrangement of the organs, textures, etc., which demand your attention :— I. External Appearances.—Number of hours after death. General aspect and condition of the body; peculiarities of person; marks on the surface; sugillation; amount of decomposition. In cases of suspected death by violence, great minuteness in the external examination is neces- sary. In unrecognised bodies the probable age, the color of the hair, and any peculiarity connected with the teeth, should be especially noticed. II. Head.—Scalp; calvaria; meninges; sinuses; choroid, plexus; brain, its form and weight; cerebellum, its weight; cortical and medul- lary substance of brain; ventricles, exact quantity of fluid in each, which should be removed with a pipette—its character; medulla oblongata;, nerves, and arteries at the base of the brain; base of cranium ; sinuses. III. Spinal Column.—Integuments over spine ; vertebrae; men- inges; cord; nerves. IV. Neck.—Thyroid gland; larynx and its appendages; trachaea; tongue; tonsils; fauces; pharynx; oesophagus; large blood-vessels; nervous trunks; cervical vertebrae. V. Chest.—Thymus gland; position of thoracic viscera; .lining membrane of bronchi; bronchial glands; pleurae; contents of pleural cavity; parenchyma of lungs; do diseased portions sink in water ? large thoracic veins; pericardium, its contents; general aspect and posi- tion of the heart; its weight; amount and condition of blood in its various cavities; right auricle; coronary veins; auricular septum; right 32 EXAMINATION OF THE PATIENT. ventricle; size of its cavity; thickness and degree of firmness of its walls; endocardium; tricuspid valve; pulmonary artery, its calibre; pulmonary veins ; left auricle; mitral valve; left ventricle; thickness and condition of its muscular tissue; size of its cavity; sigmoid valves; coronary arteries; aortic opening and arch; thoracic aorta, its structure and calibre. VI. Abdomen.—Peritoneum and peritoneal cavity; omentum; position of abdominal viscera ; omenta ; stomach ; duodenum ; small and large intestines; liver, its weight, form, and structure—its artery veins, and ducts; gall bladder and its contents; portal system; pancreas and its duct; mesenteric and other absorbent glands; spleen, its weight, size, and structure; supra-renal capsules; kidneys, weight of each ; secreting and excreting portions ; pelvis; ureters; bladder; with the prostate and urethra in the male; in the female, uterus, ovaries, Fallopian tubes, vagina; abdominal aorta and vena cava; large abdominal arteries and veins; ganglia of the sympathetic system. VII. Blood.—Appearance in the cavities of the heart, in aorta, vena cava, vena portae, etc.; congulated and fluid portions—adhesion or not of the former. VIII. Microscopic Examination of all the morbid structures and fluids, the blood, etc. etc. In carrying out the post-mortem examination, the following hints may be attended to : 1. As I have already said, the head, chest, and abdomen should always be examined, but the spinal cord and neck need not be disturbed unless the symptoms indicate some lesion there. In special cases, par- ticularly judicial ones, however, every part should be carefully inspected, and in them it may be further necessary to investigate a variety of cir- cumstances connected with the external or surgical lesion, such as frac- tures, wounds, and burns; injury to the large vessels; alterations of the organs of sense; signs of maturity and viability in new-born children, etc. etc. 2. Great care should be taken never to disfigure the body. Incisions through the skin, therefore, should be made in such directions that when the edges are afterwards sewn together, the necessary dissections below may not be visible. Neither should the body be exposed more than is needful, and delicacy demands that the genitals should always be kept covered. The wishes and feelings of friends and relations should invari- ably be held in consideration. 3. Before removing the stomach, or any portion of the intestines, a ligature should be placed above and below the tube, which should after- wards be opened with the greatest care, and the character of the contents, whether gaseous, fluid, mucous, bloody, faecal, or containing foreign substances, observed before washing and inspecting the mucous surface. This rule should be especially followed in all medico-legal investigations, in which, from neglect of it, the ends of justice have been frequently defeated. 4. You should seize every opportunity of opening dead bodies with your own hands, and acquiring dexterity in exposing the cavities, taking EXAMINATION OF THE PATIENT. 33 out the viscera, etc. Nothing is more painful than to see the brain cut into or contused, in removing the calvarium; or the large vessels at the root of the neck wounded in disarticulating the sternum, so that the surrounding parts are deluged with blood; or the cardiac valves cut through, instead of being simply exposed; or awkward incisions made into the intestines, whereby faeces escape; slipping of ligatures, etc. etc. Coolness, method, knowledge of anatomy, and skilfulness in dissection, are as necessary when operating on the dead as on the living body. 5. In examinations made at private houses, it is not always necessary to remove the viscera. The heart, lungs, liver, kidneys, etc., may be readily examined in situ. But in this Infirmary, where every facility exists, the viscera are invariably taken out, and after describing the morbid alterations they present, I shall always pass them round, so that every one present may examine them. 6. It is a good rule never to omit the examination of a morbid texture or product microscopically, until experience has made you perfectly familiar with its minute structure. 7. Notes of the examination should always be made at the time. The methodical report may be drawn up afterwards. If organs are healthy, this should be distinctly stated, so that hereafter all doubt as to their having been carefully examined may be removed. Here negative appearances are often of as much consequence as negative symptoms. 8. In describing morbid appearances, we should be careful to state the physical properties of an organ or texture, such as the size, form, weight, density, color, odor, position, etc.; and avoid all theoretical language, such as its being inflamed, tubercular, cancerous, gangrenous, and the like, as well as such indefinite description as small and large, narrow and wide, increased or diminished, etc. etc.; size should always be stated in feet and inches, and the amount of fluid in quarts, pints, or ounces. 9. The amount of care and time bestowed on the examination of an individual body will vary according to circumstances. In some cases it may require continued investigation, involving microscopical and chemical research for several days. I have never heard of a student regretting the employment of too much care in post-mortem investigation, although the occurrence of omissions from carelessness and unacquaintance with morbid anatomy are unfortunately too often exhibited by medical men in courts of justice, to the detriment of our profession in the eyes of the public, and not unfrequently to the perversion or suppression of justice.* For the correct examination of the patient in the manner described, it will be found necessary to possess an accurate knowledge of the relative position of the various internal organs. This subject is not placed so carefully before the student as it deserves—a circumstance which may probably be attributed to the fact, that anatomy is for the most part taught by surgeons. But now that physical diagnosis constitutes so necessary a part of medical education, topographical, as distinguished from * For an excellent guide to the examination of the dead body, I would recommend the practitioner and student to a work entitled, "What to Observe," published under the authority of the London Medical Society of Observation. 3 34 EXAMINATION OF THE PATIENT. surgical anatomy, is every day felt to be more necessary. I would earnestly therefore recommend the student of Clinical Medicine to study the excellent work of Dr. Sibson on Medical Anatomy, in which this sub- ject is admirably treated and illustrated. From his work I have borrowed the two accompanying figures, which exhibit at a glance the position of the internal organs in a healthy adult male after death. They also indicate the general relation of the viscera to the fixed parts of the trunk and thoracic walls, the study of which is far more useful than learning the contents of various artificial regions marked out by lines on the surface of the body. In studying all such relations of the viscera after death, it should be remembered that the organs do not occupy exactly the same position in the living body. " Expiration is the last act of life, and this last expira- tion is usually more extensive and forced than the expiration of tranquil life. In the dead body, the lungs shrink up within the position that they usually occupy during life; at the same time the heart and its vessels retract, and the abdominal organs follow the diaphragm somewhat upwards."—(Sibson.) The remarkable changes which occasionally occur in the natural position of the internal viscera may be judged of from a case which occurred to Professor Easton of Glasgow, in a pregnant female, aged twenty-seven. The enlargement of the uterus, co-operating with a gradually increasing tendency to accumulation of faeces in the lower end Fig. 1. Superficial view of internal organs after removal of the thoracic and abdo- minal parietes. Fig. 2. Deep view.—(Sibson.) EXAMINATION OF THE PATIENT. 35 of the colon, at length produced enormous distension of the sigmoid flexure, the ascending portion of which measured thirteen, and the descending twenty-five inches in circumference. The spleen and dia- phragm were forced high up to the left side, compressing the lung and displacing all the neighboring organs, so that, on elevating the ster- num and removing the ribs after death, the appearances represented Fig. 3 were ex- hibited.* In the case of Allan Brown, recorded under the head of Pleuritis, in a sub- sequent part of this work, another singular transposi- tion of viscera occurred. As the result of empyema of the left thoracic cavity,the heart was forced over to the right side. From drinking effer- vescing lemonade shortly before death, the stomach was distended with gas, and caused to twist round par- Fig. 3. tially on itself at the cardia, so that nothing could escape. The distend- ed stomach was found to occupy nearly the whole of the abdomen, and air was forced between its coats, causing emphysema of the organ. Besides the method of general examination previously detailed, it is further essential to employ various special modes of investigation. These are inspection, palpation, mensuration, percussion, auscultation, the use of the microscope and of chemical tests. To them we are indebted for that precision and certainty which characterise the results of physical science. Up to a comparatively recent period medical men formed their diagnosis and prognosis of internal diseases from an observation of functional symptoms. But as these—being often only the sensations of the patient —may vary from hour to hour according to accidental circumstances, while the pathological lesions which occasion them remain the same, they are most uncertain. Formerly it was imagined that every morbid organic change gave rise to a certain train of symptoms, and that a knowledge of these was all-sufficient to determine the structural malady. But this idea is negatived by clinical observation, which teaches us that many different lesions have the same symptoms; and that, occasionally, most important and even fatal organic diseases have no symptoms at all. Cases of fatty heart, and atheromatous degeneration of the cerebral blood-vessels, often give rise to no symptoms whatever until death suddenly supervenes by * Monthly Journal of Medical Science, Dec. 1850, p. 494. Fig. 3. Remarkable displacement of organs, in consequence of intestinal obstruc- tion, a, Caput coli; b, ascending portion of sigmoid flexure; c, descending portion; d, gravid uterus turned a little down.—(Easton.) 36 EXAMINATION OF THE PATIENT syncope or coma. Hence, whenever physical exploration is applicable, it should be had recourse to, In addition to an investigation of the symptoms. It is in a great measure owing to our superior knowledge in this respect that medicine has made such great advancement during the present century. INSPECTION. Inspection of a part or of the wholo surface of the body in various positions is often of the utmost importance. The latter is necessary in the examination of army recruits, but can seldom be carried out rigorously in hospital, and still less in private practice. Delicacy forbids it in females. The part affected, however, ought always to be seen, a neglect of which rule has led to numerous errors. The various eruptions which appear on the surface of the body are spoken of in another place. Here I shall only shortly allude to the inspection of the general posture, of the counte- nance, of the thorax, of the abdomen, of the pharynx, of the larynx, and of the posterior nares. Inspection of the general posture of the patient in repose and in motion is often highly diagnostic. Thus the position and attitude assumed by the body in cases of fever, in acute inflammations, in hemi- i plegia or paraplegia, in hydrothorax and asthma, in colic or spasmodic diseases, and even in various forms of insanity, are very characteristic. The description of these, however, belongs to the consideration of indi- vidual diseases. As a general rule, the supine position denotes muscular debility—quick and forcible changes of position indicate excitement of the nervous system or spasm—whilst fixed and restrained movements are dependent on paralysis or inflammatory pain. Inspection of the countenance is a matter of such importance as to be instinctively practised, with a view of determining the amount of pain, disturbance of the feelings, or general mental and bodily condition of the patient. A thorough knowledge of the indications so presented to the physician is only to be attained by long experience in the observa- tion of disease. The cuticular surface may be so altered as to give a peculiar appearance to the complexion, especially in chronic diseases of the digestive system. The changes in the blood-vessels and blood occasion pallor or flushing; the sallow and yellow hue observed in some disorders; the state of tumidity or shrinking, of heat or coldness, and of dryness or moisture. Alterations in the subcutaneous and muscular tissues produce emaciation, or oedema, languor, and various kinds of convulsion or paralysis. The individual features also require to be studied, especially the eye and mouth. Pain, if in the head, causes the brow to corrugate; if in the chest, the nostrils to be drawn upwards; if in the abdomen, the lips to be raised and stretched over the gums and teeth. These changes are more readily observed in children, in whom they are not under the control of the will. Inspection of the Chest.—This refers to the form and configuration of the entire thorax, or its various parts, and to a careful comparison of the two sides when at rest and when in motion. It is often difficult, in cases where changes are not well marked, to determine them by mere BY INSPECTION. 37 inspection. To do so, a good light and proper position, both of the observer and of the patient, are necessary. The observer should, if possible, be directly in front of the patient, and whenever the case admits of it, the latter should be in the sitting posture. The chest may be so altered in disease as to be irregular or unsymmetrical, from dis- tortions, congenital or acquired, in the bones of the vertebral column or of the thoracic walls. Various portions of it may be expanded or bulge out, as in cases of empyema or thoracic tumors ; or it may be retracted and depressed, as occurs in chronic phthisis. A case presented itself to the late Dr. Spittal at the Royal Dispensary of this city, where the re- traction was so great on one side that the student in charge of it had placed compresses on the sound side, in the belief that the healthy prom- inence there was indicative of a tumor. The motions of the chest bear reference to inspiration and expiration,* which pass imperceptibly into one another, and can be made more rapid or prolonged voluntarily. A forced inspiration gives rise to more thoracic movement in the female than in the male, in whom it is more abdominal. In disease these motions are altered in various ways—1st, By general excess or diminu- tion, as in cases of spasmodic asthma or laryngeal obstruction. 2d, By partial immobility, as in pleurisy; or by augmented expansion, as in the side not affected in a pneumonia or pleurisy. 3d, By increased rapidity, as in pericarditis; or unusual slowness, as in coma. Inspection of the Abdomen. — The abdomen in health is slightly convex, and marked by elevations and depressions, corresponding to the muscles in its walls, the umbilicus, and prominences of the viscera below. It varies according to age and sex—in youth being smoother and flatter than in the adult, and in females being broader inferiorly than in males, from the greater width of the pelvis. In disease it may be, 1st, enlarged generally and sym- metrically, as in dropsies, or partially, and irregularly, from ovarian, hepat- ic, splenic, and other tumors; 2d, it may be retracted—generally, from ex- treme emaciation, or partially, from local intestinal obstruction. The su- perficial abdominal veins are sometimes greatly enlarged, and at others dis- tiuet pulsations are visible, dependent on deep-seated cardiac or arterial disease. The abdomen, like the chest, is in constant movement in connec- tion with the act of respiration, being more prominent during inspiration, * " During inspiration, the clavicles, first ribs, and through them the sternum, and all the annexed ribs, are raised; the upper ribs converge, the lower diverge ; the upper cartilages form a right angle with the sternum, and the lower cartilages of opposite sides, from the seventh downwards, move further asunder, so as to widen the abdominal space between them, just below the ziphoid cartilage; the effect being to raise, widen, and deepen the whole chest, to shorten the neck, and apparently to lengthen the abdomen. During expiration, the position of the ribs and cartilages is reversed ; the sternum and ribs descend ; the upper ribs diverge, the lower converge; the upper cartilages form a more obtuse angle with the sternum, and the lower carti- lages of opposite sides approximate, so as to narrow the abdominal space between them, just below the ziphoid; the effect being to lower, narrow, and flatten the whole chest, to lengthen the neck, and apparently to shorten the abdomen. It is to be observed, that during inspiration, while the ribs and sternum are moving upwards, the lungs and heart, and the abdominal organs, are moving downwards, and that, consequently, viewed in relation to the ribs, the descent of the internal organs appears to be greater than it really is."—(Sibson.) 38 EXAMINATION OF THE PATIENT and flattened during expiration. These respiratory movements of the ab- domen bear a certain relation to those of the chest, being often increased when the latter are arrested, and vice versa. Thus, in pleurisy, the re- spiratory movements are mostly abdominal, whereas in peritonitis, they are altogether thoracic. The variations observable in the disturbed rela- tions of the respiratory movements in the thorax and abdomen are often highly instructive, especially in cases of dyspnoea from hydrothorax, spasmodic asthma, anaemia, ascites, abdominal tumors, etc. Inspection of the Pharynx.—For this purpose a broad spatula firmly mounted in a handle at right angles is necessary to depress the tongue. Such spatulae are now easily procurable of different forms in all surgical- instrument makers' shops, the most convenient being those here figured, Fig. 4. Fig. .. (Fig. 4)._ The greatest difference exists in various persons as to the freedom with which they can bear pressure on the dorsum of the tongue. In some that organ can be readly depressed, and the top of the epiglottis brought into view without causing any inconvenience. In others this cannot be done without exciting cough, or sensations of suffocation or sickness. In a few, the parts are so sensitive that the slightest touch induces spasms. These latter cases are rare, and reiterated efforts in the vast majority of instances, by educating the parts as it were to submit to interference, en- able the practitioner, after a shorter or longer time, easily to bring into view the tonsils, pillars of the fauces, uvula, back of the pharynx, and upper edge of the epiglottis. In this manner enlargement or ulcerations of the tonsils or uvula can be readily seen, as well as the various morbid ulcerations of the mucous membrane. Among these, follicular pharyngitis Fig. 4. Spatulae for depressing the tongue— one-third the real size Fig. :>. Extreme case of follicular pharyngitis, shown by the tongue-depressor — (After Horace Green.) > ° ^ BY INSPECTION. 39 is the most common, red circular swellings, in the form of split peas, being scattered more or less thickly over the surface. Occasionally these are aggregated together, as in the extreme case now figured (Fig. 5). Inspection of the Larynx.—The idea of illuminating and rendering the larynx visible by means,of a reflector has been more or less attempted by Liston, Warden,* Avery, Garcia, and others, but abandoned as impractica- ble in medicine, until successfully revived in recent times (1858-59) by Professor Czermak, of Pesth. For the examination of the larynx he employs, 1st, a perforated mirror, by means of which a powerful light is thrown from a lamp into the back of the mouth, and through which the operator gazes in the direct axis of the illuminating rays. This mirror may be attached to a bent stalk, the end of which can be held firmly by the teeth, but is far more conveniently attached to the framework of a pair of spectacles, or to a band passing around the head. 2d, A laryngeal mirror of glass or steel, varying in size, attached to a stem at one of its corners, which having been previously warmed to prevent condensation of the breath upon it, is placed against the uvula, and reflects the image of the rima glottidis to the eye of the observer. The following directions are given by Czermak :—" The person ex- amined places his hands upon his knees, the upper part of the body is advanced forwards, the neck bent onward, the nape slightly inclined backwards, the mouth widely open, the tongue flattened and held a little without. The observer is seated in front of the person to be examined; he places in his mouth the handle which supports the illuminating mirror, and looks through the central opening ; the laryngeal mirror, introduced into the back part of the mouth with the right hand is illuminated by the light which is projected from the illuminating mirror ; the left hand can be placed upon the shoulder of the person examined, and steadies the chin and the nape, or holds a tongue-depressor, which he can often trust to the patient himself. In the first place, the illumination of the back part of the mouth and the mutual position are regulated; then the laryngoscope is heated, and its temperature regulated by the touch. After these pre- liminaries are gone through, we request the patient to open the mouth wide, and alternately to inspire deeply and to pronounce the sound ah ; during this we endeavor to place the back of the laryngoscope against the uvula and the velum palati, to sustain these parts a little, and to give the mirror a convenient inclination ; at times it is impossible to avoid touching the posterior wall of the pharynx ; the examination is directed by the image we thus obtain. In this way we commence each laryngoscopic ex- amination. Practice and reflection will bring each observer to compre- hend the modifications to which he ought to submit this proceeding, ac- cording to the special circumstance ; whether, for instance, he is in some degree to advance or to withdraw the laryngoscope, to bend it, to lower or to elevate it, to change the position and attitude of the individual un- dergoing examination, raise his chair, etc." The method which I have found most convenient for examining the larynx with these instruments is seen in the accompanying diagram. When * Dr. Warden of Edinburgh distinctly showed the larynx in 1845 by means of a spatula and a reflecting prism invented for the purpose.—Edinburgh Monthly Journal of Medical Science, 1845, p. 552. 40 EXAMINATION OF THE PATIENT direct sunlight cannot be obtained—which is always the best method of illumination—a brilliant gas jet, the glare of which is screened from the eyes of the operator by a shade, answers very well. This should be placed near the ear of the patient, on the side opposite to the eye employed of the observer, in order to diminish, as much as possible, the inclination of the Fig. 6. reflector forwards. A brilliant light is absolutely essential, and is readily obtained by a globe of glass, six inches in diameter, filled with water, as recommended by Dr. Walker.* Instead of the tongue-depressor, the tongue may be drawn forward and held by its tip with the hand and a towel, and if the patient can do this himself the examination is facilitated. The appearances of the larynx when closed moderately and fully dilated, FiS- 9- Fig. 10. as shown in himself or in others, are represented by Czermak in a state of * The Laryngoscope, 1864, p. 13. Fig. 6. Mode of using the laryngoscope and tongue-depressor. The light is ob- tained from a movable gas jet, the glare of which is screened from the observer by a shade mounted on a stand. BY INSPECTION. 41 health, in the accompanying figures. When widely dilated, and the neck straightened, the cartilaginous rings of the trachea and bifurcation of the bronchi have been made visible. These appearances are greatly modified in disease, when oedema, ulcerations, cicatrices, morbid growths, or irreg- ularities in the form of the glottis and mucous membrane, are readily detected, of which several interesting cases have already been published. Fig. 11. Fig. 12. Fig. 13. Fig 14. As the use of the laryngoscope extends these will of course become more numerous. The rendering ulcers and morbid growths visible by the laryngoscope, not only establishes an exact diagnosis, but permits of the direct application of means for their cure or removal. Fig. 1. View of the healthy larynx with the laryngoscope, when the vocal cords are closed as in sounding high notes.—(Czermak.) Fig. 8. Another view of the healthy larynx during ordinary breathing.—(Czermak.) Fig. 9. Another view during deep inspiration, with the trachea straight, showing the glottis widely dilated, and through it the rings of the trachea and bifurcation of the bronchi.—(Czermak.) In the three last figures the numbers indicate the following parts:—1, Base of the tongue; 2, Posterior wall of the pharynx; 3, Entrance of tha oesophagus, the line of demarcation between the wall of the pharynx and the posterior surface of the larynx; 4, Epiglottis; 5, Arytenoid cartilages; 6, Cushion of the epiglottis; 1, Aryteno- epiglottic ligament; 8, Tubercle corresponding to the cartilage of Wrisberg; 9, Tuber- cles of the cartilages of Santorini; 10, Tubercle which sometimes exists between the two preceding; 11, Process of the arytenoid cartilages; 12, Inferior vocal cords ; 13, Superior vocal cords; 14, Ventricles of Morgani; 15, Anterior wall of the trachea; 16, Posterior wall of the trachea; 11, Right bronchus ; 18, Left bronchus. Fig. 10. Complete closure of the glottis as in the act of swallowing.—(Czermak.) Fig. 11. Transformation of the right (inferior) false vocal cord into a hard, rough, and ulcerated mass.—(Czermak.) Fig. 12. Cicatrices and loss of substance of the larynx.—(Czermak.) Fig. 13. Polypus attached to the right vocal cord, the real cause of a supposed nervous aphonia.—(Czermak.) Fig. 14. Large muriform polypus of an epithelial character.—(Czermak.) 42 EXAMINATION OF THE PATIENT Fig. 13. Fig. 16. of the parts. Dr. Voltolini of Breslau has also pointed out the great advantage of this mode of exploration in the diagnosis and treatment of diseases of the ear. He recommends, instead of a spatula for depressing the tongue, a shield of gutta percha, a portion of which is raised up to Fig. 15. 1—6, section of the six upper cervical vertebrae; o, a section of the basilar process of the occipital bone; s, a section of the body of the sphenoid bone and sinus; g, a section of the crista galli of the ethmoid bone; /, a section of the frontal bone and sinus; n, os nasi of the left side; m, the palate process of the superior maxillary bone separating the mouth from the nasal fossa); v, the posterior or pharyngeal edge of the vomer; d, the opening of the Eustachian tube ; pu', a sec- tion of the soft palate and uvula, indicating the normal position of these parts; pu, the soft palate and uvula drawn forwards and upwards by the hook (K); ph, the pharynx; t, the tongue; j, a section of the inferior maxillary bone; h, a section of the hyoid bone; e, L, a section of the epiglottis and larynx; tr, the trachea. The external wall of the left nasal fossa is indicated by dotted lines; a, b, c, the tur- binated bones; x, x', two different positions of the rhinoscopic mirror; xy, x'y', two different directions of the light and sight.—(Czermak.) Fig. 16. Mirror and shield for depressing the tongue, useful in the examination of the posterior nares and orifices of the Eustachian tubes; half the real size.— (Voltolini.) BY PALPATION. 43 admit the passage under it of the handle of the mirror strengthened for that purpose. In this manner the mirror can be directed upwards and the tongue depressed with one hand,* a matter of great importance, as the other hand must be employed in pulling forward the uvula. Even when the patient depresses his own tongue, which is seldom done by him efficiently, it will be found difficult, unless the hand which manipulates the rninoscope be kept low, as in depressing the tongue, to pre- vent its interfering with the rays of light The application of these instruments management of the light, and overcoming the irritability of the parts concerned, often require the exercise of patience and perseverance in the practitioner. In this also, a3 in every other method of physical exploration, practice and dexterity of manipulation are required. Perse- verance and skill in their employment, however, cannot fail, in appropri- ate cases, to improve our means of arriving at an exact diagnosis, and thereby of extending the domain of medical science.! PALPATION. Palpation also is a necessary mode of examination, and is sometimes practised by simply applying the tips of the fingers, at others by placing the hand on the part affected, and not unfrequently by employing both hands, and pressing with them alternately. This latter method is most applicable in endeavoring to judge of tumors, especially when large or deep seated, and situated in the abdomen. The position of the patient during palpation must be varied -according to the part examined. The horizontal posture is best to judge of deep-seated pulsations and vibra- tions, but sometimes the erect posture, or even leaning forward, becomes necessary, as when the heart is being examined. When feeling the abdominal organs through the integuments, these last should be relaxed by causing some one to flex the inferior extremities on the abdomen, and push the head and neck forwards. In this manner palpation affords information—1st, As to the increased or diminished sensibility of various parts; 2d, Of their altered form, size, density, and elasticity; and, 3d, Of the different kinds of movement to which they may be subjected. 1. When pain is experienced in any part, it is generally increased by pressure and movement, if inflammatory, but relieved if neuralgic. Not unfrequently pressure causes pain or tenderness where otherwise * Virchow's Archiv., Band. 21, s. 45. f For full details and numerous interesting cases, see Czermak on the Laryngo- scope in the "Selected Monographs" of the New Sydenham Society for 1861. Also the works of Drs. Gibb and Walker. Fig. 17. Septum, posterior orifices of the nasal fossse, turbinated bones, and orifices of the Eustachian tubes. The posterior arched surface of the velum covers the inferior part of the nasal cavity.—(Czermak.) 44 EXAMINATION OF THE PATIENT neither are experienced. Thus deep pressure in the right iliac region causes pain in typhoid fever, which, however, must be judged of from the expression of the countenance, rather than the statement of the patient. Again, over the vertebral column pressure or percussion may induce pain that is otherwise not felt. In paralytic cases the diminution of sensibility can only be ascertained by feeling or pinching the part, and the limitation of anaesthesia is best arrived at by pricking the sur- face with some pointed hard substance. 2. Alterations in external form and size may be judged of by inspec- tion, but with regard to internal organs, especially abdominal ones, we derive more exact information from palpation conjoined with percussion, as in cases of hypertrophied liver and spleen, or when some tumor exists. In such cases we can feel from the increased density and resist- ance the size and outline of the morbid growths, which will be more or less distinct, in proportion as they are near the surface, and circumscribed in form. Occasionally organs are diminished in size, and cannot be felt in their normal positions, as when the inferior margin of the liver cannot be detected in this way, from atrophy. The natural elasticity of parts may also be increased or diminished. Thus the abdomen is more elastic when air is in excess in the intestines, and less so when the peritoneum contains liquid. The integuments also may be more rigid and indurated, as in chronic skin diseases, or, on the other hand, soft and doughy, as in oedema, when they pit on pressure, from diminished elasticity. 3. Certain motions in the thoracic and abdominal cavities, as well as in other parts of the body, are best judged of by palpation. It is in this way that the character and situation of pulsation at the heart, root of the neck, or elsewhere, are determined. The expansive motion of the thorax and abdomen during respiration is also thus ascertained. If we place the two hands, with the fingers spread out like a fan in the axillae or flanks, and bring the two thumbs towards each other, near the sternum or umbilicus, we can judge by their approach and separation of the amount of expansion or retraction that takes place. Application of the hand also allows us to detect undulatory motions below the integument, and to determine the existence of vibrations, frictions, gratings, and crepi- tations. Rostan relates a case where all the symptoms of acute intercos- tal rheumatism were present (which disease was diagnosed), caused by a broken rib, that was overlooked from the diseased part not having been examined by palpation. There is a natural fremitus or thrill perceptible on placing the hand on the chest, when a person is speaking, which is increased in some diseases of the chest, and lessened in others. This sensation is also sometimes felt over the large blood-vessels. It resembles more or less the vibration felt on placing the hand on the back of a cat while purring. Fluctuation is another sensation, caused by pressing on or percussing parts in such a way as to cause displacement of their con- tained fluids. A modification of it is known under the name of succussion, which is effected by shaking the patient—a proceeding, however, which •is seldom necessary. BY MENSURATION. 45 MENSURATION. The simplest way of measuring the circumference of parts, or the distance between any two fixed points, is by means of a graduated tape. In ascertaining the circular measurement of the chest or abdomen, that moment should be chosen when the patient holds his breath at the end of an ordinary expiration, great care being taken that the tape is carried evenly round the body. The relative mensuration of the two sides of the chest or abdomen is best accomplished by choosing the spinous processes of the vertebras as fixed points on the one hand, and a line drawn through the centre of the sternum and umbilicus on the other. The exact levels of the measurements should always be noted, such as at the nipples, margin of the lower ribs or umbilicus, which are those most Fig. 18. . Fig. 19. deserving of observation. The diameter of the trunk in various direc- tions is best ascertained by means of a pair of callipers. The amount of motion in the chest and abdomen, and of its various parts, is capable of being accurately determined by means of the chest- measurer of Dr. Sibson (Fig. 20), or the stethometer of Dr. Quain (Fig. 18). Both instruments are composed of a brass box, having a dial and an index, which is moved by a rack attached to a prolonged pinion or a string. One revolution of the index indicates an inch of motion in the chest; the intervening space being graduated. It has been found necessary, when making observations on the respiratory movements, whether of the chest or of the abdomen, to divert the patient's attention, and make him look straight forwards, otherwise these movements become so affected as to vitiate the results. The instruments may be applied in the sitting or recumbent posture. The method of applying them with a string attached is shown in Fig. 19, and the mode of using Dr. Sibson's chest-measurer by placing the pinion on the nail of the observer's finger, Fig. 18. The stethometer of Dr. Quain—half the real size. Fig. 19. Mode of applying the instrument when the string is used.—(R. Quain.) 46 EXAMINATION OF THE PATIENT moving with the chest, is seen Fig. 21. If held in the hand, as in Figs. 19 and 21, great steadiness and care are requisite to arrive at exact results. Dr. Sibson's instrument may be attached to brass rods, which are bent at right angles, so as to present the form of ]. The upper arm is movable, and admits of elongation by means of a split tube, so that in this way great steadiness is arrived at, while the instrument itself can be carried Fig- 20. Fig. 21. to any part of the chest or abdomen, without disturbing the position of the patient,, as seen in Fig. 22. There is, however, considerable variation even in health in different persons. Some, for instance, can cause the second rib to advance two and a quarter inches during forced inspiration, whilst others can only cause it to advance three quarters of an inch. The motion of the whole left side, excepting that of the second rib, is somewhat less than on the right side. It should also be remembered that the motion of the tenth rib indicates that of the diaphragm. The pressure of the stays in the female exaggerates the thoracic and diminishes the abdominal movements. Fig. 20. The chest-measurer of Dr. Sibson, natural size Fig. 21. Mode of applying the chest-measurer.—(Sibson.) BY MENSURATION. 47 According to the observations of Dr. Sibson, made with this instru- Fig. 22. ment, tho respiratory movements in health may be thus represented in 100th's of an inch. Instrument applied to Sklo. Involuntary tranquil respiration Voluntary forced respiration about Centre of sternum between 2d costal cartilages..................... (right" ^ left ( right 7 left j right I left j right Heft f centre \ bo? J | man ] right [kft i 3 to 6 100 2d Rib near the costal cartilage.... 3 " 1 3 " 1 2 " 6 3 " 6 2 " 5 5 3 10 9 25 25 to 30 9 8 110 110 95 95 85 10 60 65 60 90 100 5th Costal cartilages near the rib... 6th Rib at the side............... 10th Rib....................... In disease it may be observed as a general rule, that if the respira- tory movements are restrained in one place, they are increased elsewhere. We have already alluded to the relation existing between thoracic and abdominal movements (see Inspection). The amount of these may be exactly ascertained by the chest-measurer. In the same manner the di- minished movements on one side of the chest in pleuritis, pneumonia, and incipient phthisis, can be determined and compared with the ex- aggerated motion on the opposite. Thus in phthisis, instead of the indicator of the instrument placed over the second rib, on the affected side, moving between 1 and 110 on forced inspiration, as in health, it may only move between 1 and 30. In making observations with the chest-measurer, considerable practice and skill are necessary, as in the employment of all other instruments. It enables us to arrive at great accuracy, and constitutes an extra means of exploration, without, how- Fig. 22. Mode of application of the chest-measurer, attached to brass rods, bent it nght angles, when the patient is in the horizontal posture.—(Sibson.\ 48 EXAMINATION OF THE PATIENT ever, being absolutely necessary for arriving at a correct diagnosis in every case. The expansibility of the lungs, and the amount of air expelled from the chest after full inspiration, may also be measured by the spirometer of Mr. Hutchinson. But the necessity of determining the height and weight of the individual, of teaching him how to inspire and expire, of paying attention to the muscular force and other circumstances, so inter- feres with the correct conclusions to be derived from this mode of ex- ploration, a3 to render it valueless in the examination of cases gene- rally. As a means of physiological research in determining the vital capacity of the chest, Mr. Hutchinson's investigations are of the utmost importance. Dr. Scott Alison has invented an instrument for measuring the an- gles of the chest. It will also enable us to judge approximatively of the curves under various altered conditions. He calls it stetho-goniometer, a term derived from three Greek words, signifying chest, angle, and measure. Dr. S. Alison believes that it will afford data not to be ob- Fig. 23 obtained by other means, and assist in the diagnosis of disease in its early as well as in its later stages.* PERCUSSION. The object of percussion is to ascertain the resistance and size of organs. It may be practised directly, or through the me- dium of an interposed body (mediate percussion) — the last being the only satisfac- tory way. Without knowing how to strike, and to produce clear tones, we can never edu- cate the ear, or the sense of resistance. This preliminary education in the art of percussion requires a certain dexterity, which some find it very difficult to obtain. The difficulty seems to depend, in * Beale's Archives of Medicine, vol. i. p. 60. Fig. 24. Fig. 23. Stetho-gomometer, for measuring the inclination of different parts of the walls of the thorax in cases of disease, aa, The arms; b, the arc of a circle graduated; c, the vernier, with an arrow, also graduated; d, vernier arm; e, joint.—(Scott Alison ) BY PERCUSSION. 49 some cases, on an alteration in the proportions usually existing between the length of the fingers. Thus, I have seen more than one person who had the index finger nearly an inch shorter than the middle one, and who, consequently, found it impossible to strike the pleximeter fairly with the tips of the two fingers at once. By far the most common cause of failure, however, is want of patience and perseverance in overcoming the first mechanical difficulties; and there is every rea- son to believe that could this be surmounted, accu- rate percussion would become more universal and better appreciated. Without entering into the nu- merous discussions which have arisen as to the supe- rior advantages of one plan as compared with another, or of using this or that instrument, I may mention, that for the last twenty-three years I have employed a pleximeter and a hammer. These instruments I can confidently recommend to you as the readiest means of obtaining accurate results at the bed-side by means of percussion. The ivory pleximeter I use is that of M. Piorry, as modified by M. Mailliot. Its length is two inches, and breadth one. It possesses two handles, and an inch and half scale drawn upon the surface. It may be applied with great precision to every part of the chest, even in emaciated subjects (Fig. 24). The hammer is the invention of Dr. Winterich of Wurzburgh. The advantages it possesses are,— 1st, That the tone produced by it, in clearness, pene- trativeness, and quality, far surpasses that which the most practised percusser is able to occasion by other means. 2d, It is especially useful in clinical instruc- tion, as the student most distant from the patient is enabled to distinguish the varieties of tone with the greatest ease. 3d, It at once enables those to percuss, who, from peculiar formation of the fingers, want of opportunity, time, practice, etc., are deficient in the necessary dexterity (Fig. 25).* With the assistance of the instruments I now recommend to you, every student acquainted with the relative situations of the different thoracic and abdominal organs, is himself enabled, without other preliminary education, to detect the different degrees of sonoriety they possess in a state of health and disease. I may say, that by means of these instru- ments, after one hour's practice on a dead body, he Fig. 25. is placed on a par (as regards the art of percussion) * The hammer and pleximeter are carefully made by Mr. Young, cutler, North Bridge, Edinburgh—in a neat case, price 7s. 6d. 4 50 EXAMINATION OF THE PATIENT with the generality of experienced practitioners in this country; and any of you, after one month's employment of them, will be enabled to mark out accurately on the surface of the body, the size and form of the heart, liver, spleen, etc. I have tried a smaller and lighter hammer kindly sent to me by Dr. Winterich, as well as balls surrounded by thick rings of caoutchouc, and attached to elastic pieces of whalebone. But a certain weight is neces- sary to obtain a penetrative sound, and rigidity of the handle is necessary to judge of the sense of resistance. In my opinion, no better hammer has been invented than the one figured on the preceding page. Of the Different Sounds produced by Percussion. The sounds produced by percussion arise from the vibrations occa- sioned in the solid textures of the organ percussed. The different density and elasticity of these textures will of course more or less modify the num- ber and continuance of the vibrations, and give rise to different sounds. M. Piorry considers that nine elementary sounds are thus formed, which he has designated, from the organ or part which originates them, " femoral, jecoral, cardial, pulmonal, intestinal, stomacal, osteal, humo- rique, and hydatique." I consider that all these sounds may be reduced to three elementary ones; that, in point of fact, there are only three tones occasioned by percussion, and that all the others are intermediate. These three tones are respectively dependent,—1st, On the organ con- taining air; 2d, On its containing fluid; and 3d, On its being formed of a dense uniform parenchymatous tissue throughout. These tones, therefore, may be termed the tympanitic, the humoral, and the paren- chymatous. Percussion over the empty stomach gives the best example of the first kind of sound; over the distended bladder, of the second; and over the liver, of the third. Certain modifications of these sounds occasion the metallic and the cracked-pot sound. The latter is made audible over the chest under a variety of circumstances, by percussing with the mouth open. The terms jecoral, cardial, pulmonal, intestinal, and stomacal, however, may be used to express those modifications of sound produced in percussing respectively the liver, heart, lungs, intes- tines, and stomach. No description will suffice to convey proper ideas of the various alterations of tone occasioned by percussing over the different thoracic and abdominal viscera. To become acquainted with these, it is absolutely necessary to apply the pleximeter to the body, and then half an hour's practice with this instrument and the hammer will be sufficient to render any one conversant with those which may be heard in a normal state. It must be remembered, however, that the tones even then may vary according to circumstances. Thus, immediately after a deep inspiration, the pulmonal sound will be rendered more tympanitic, and, after expira- tion, more parenchymatous. In the same manner the stomach and in- testines may give out different sounds according to the nature of their contents. In the left or right iliac fossa a clear tympanitic sound will be heard when the intestine below is empty, and a dull parenchymatous sound when it is full of faeces. BY PERCUSSION. 51 A study of the different modifications of sound, which various organs thus produce in a state of health, readily leads to the comprehension of the sounds which may be elicited in a morbid state. Thus, the lungs may occasion a dull or parenchymatous sound, from solidification, the result of exudation, or, on the other hand, become more tympanitic, from the presence of emphysema. The abdomen may give out a parenchy- matous sound, from enlargement of the uterus or an ovarian tumor; or a dull humoral sound, from the effusion of fluid into the cavity of the peritoneum. Of the Sense of Resistance produced by Percussion. By the sense of resistance is understood the peculiar sensation re- sulting from those impressions which are communicated to the fingers on striking hard, soft, or elastic bodies. It is of the greatest service in determining the physical condition of the organ percussed. The sense of resistance bears relation to the density of the object struck,—hence, firm and solid textures offer more resistance than those which are soft or elastic. The thorax of a child is elastic, whilst that of the adult is un- yielding. Of all the thoracic and abdominal organs, the liver presents the greatest degree of resistance, and the stomach the least. The pres- ence of fluid in the hollow viscera offers an amount of resistance between the parenchymatous organs on the one hand, and those containing air on the other. But air much condensed, or fluid contained within the rigid walls of the thorax, may offer a considerable degree of resistance. The sense of resistance should be as much educated by the physician as the sense of hearing, and it would be difficult for an individual, prac- tised in the art of percussion, to say which of these two points is the more valuable to him. Both are only to be learnt by practice, and consider- ing it perfectly useless to describe that in words which may be learnt in half an hour, by the use of the pleximeter and hammer on a dead body, or the living subject, I shall now proceed to describe the General Rules to be followed in the Practice of Mediate Percussion. 1. The pleximeter should be held by the projecting handles between the thumb and index finger of the left hand, and pressed firmly down upon the organ to be percussed. Much depends upon this rule being followed, as the sound and sense of resistance are considerably modified according to the pressure made by the pleximeter. A very easy expe- riment will prove this. If, for instance, the pleximeter be struck while it rests lightly on the abdomen over the umbilicus, and again, when it is pressed firmly down amongst the viscera, the change in tone will be at once perceived. In the first case, a dull sound is produced, from the muscles and integuments being alone influenced by the force of the blow; in the second case, a clear tympanitic sound is occasioned from the vibra- tion of the walls of the intestine. In every instance, therefore, the pleximeter should be so held and pressed down, as to render it, so to speak, a part of the organ we wish to percuss. 52 EXAMINATION OF THE PATIENT 2. Great care must be taken that no inequality exist between the inferior surface of the pleximeter and the skin. Firmly pressing it down will always obviate this when the abdomen is examined. As re- gards the thorax, the groove over the anterior mediastinum, the promi- nence of the clavicles and of the ribs, in emaciated subjects, may allow a hollow to exist under the instrument, by which a deceptive tympanitic sound is occasioned. By a little management, however, with the small and oval pleximeter I have recommended, this may readily be avoided. 3. The hammer should be held, as advised by Dr. Winterich, be- tween the thumb and the first and third fingers, the extremities of which are to be placed in hollows prepared for them in the handle of the in- strument. By some these are considered useless, but in all cases where slight differences in tone are to be appreciated, I have found this the best mode of employing it. Ordinarily, however, it will be sufficient to hold it by the extremity of the handle, merely in such a manner as will enable the practitioner to strike the pleximeter lightly, or with force, as occasion may require. 4. Care must be taken to strike the pleximeter fairly and perpen- dicularly. Unless this be done, vibrations are communicated to textures in the neighborhood of the organ to be percussed, and fallacious results are the consequence. If in percussing the lungs, for example, the blow be made obliquely, we obtain the dull sound produced by the rib, and I have seen considerable error in the diagnosis thus occasioned. 5. A strong or gentle stroke with the hammer will modify the tone and sense of resistance, inasmuch as the impulse may be communicated by one or the other to a deep-seated or a superficial organ. Thus a gentle stroke will elicit a pulmonal tympanitic sound just below the fourth rib, where a thin layer of lung covers the liver, but a strong one will cause a jecoral parenchymatous sound. At the inferior margin of the liver, on the other hand, where a thin layer of the organ covers the intestines, the reverse of this takes place, a gentle stroke occasioning a dull, and a strong one a clear sound. 6. By withdrawing the hammer immediately after the blow, we are better able to judge of the sound; by allowing it to remain a moment, we can judge better of the sense of resistance. 7. The integuments should not be stretched over the part percussed, as when the stethoscope is employed, for an unnatural degree of resist- ance is thus communicated to the hand of the operator from the muscu- lar tension. In every case, especially where the abdomen is examined, the integuments and superficial muscles should be rendered as flaccid as possible. 8. It is always best to percuss on the naked skin. It is not abso- lutely essential, however ; and in cases where, from motives of delicacy, it is desirable that the chest or abdomen be not exposed, it only becomes necessary that the covering of linen or flannel be of equal thickness throughout, and not thrown into folds. 9. When percussion causes pain, the force of the blow must of course be diminished. Under such circumstances, however, it will often be necessary to distrust the results. 10. The position in which the individual examined should be placed, BY PERCUSSION. 53 will vary according to the organ explored. In percussing the thoracic organs and the liver, a standing or sitting position is most convenient. The stomach, intestines, uterus, bladder, and abdominal tumors or effusions, are best examined when the patient is lying on the back, with the knees flexed so as to relax the abdominal walls, and, if necessary, the head and neck bent forward, and supported by pillows. In percussing the spleen, the individual should lie on the right side; and when the kidneys are examined, he should lie on the breast and abdomen. In cases of effusion into the serous cavities, a change of position furnishes most valuable indications. 11. In percussing any particular organ, the pleximeter should be first applied over its centre, where the sound and sense of resistance it may furnish are most characteristic. Two blows with the hammer are gene- rally sufficient to determine this. From the centre, the pleximeter should be moved gradually towards the periphery, or margin of the organ, and struck as it proceeds with the hammer, now forcibly, now lightly, until the characteristic sound of the next organ be elicited. The pleximeter is then gradually to be returned towards the organ under examination, until the difference of tone and sense of resistance become manifest. In this manner having first heard the two distinct sounds well characterised, we shall be better enabled to determine with accuracy the limit between the one and the other. This may be done exactly, after having deter- mined whereabouts the line of separation is, by placing the long diameter of the pleximeter transversely across it, and striking, first one end of the instrument, and then the other, till the precise spot is determined. This spot should now be marked, by placing with a pen a dot of ink on the skin, or employing for this purpose a very soft black-lead pencil. The oppo- site and then other portions of the margin of the organ should be limited in the same manner, and these in turn should be marked until the whole organ be completely examined. Then by uniting all these marks with a line of ink or pencil, we have the exact form of the organ drawn upon the skin. When it is thought necessary to render the first line permanent, in order to see if any subsequent change take place in the size of the organ, or extent of the dulness, it may be rendered so by carrying lightly over the ink line a stick of nitrate of silver previously moistened. Special Rules to be followed in Percussing Particular Organs, Before proceeding to percuss individual organs in persons laboring under disease, you should obtain a general knowledge of the limits and intensity of dulness on percussing the thoracic and abdominal viscera in health. The accompanying figures convey this information with great accuracy, the depth of tint corresponding to the dulness of tone and amount of resistance. The normal sonoriety and dulness exhibited (Figs. 26 and 27) will enable you to compare with readiness the altera- tions revealed by percussion under a variety of diseased conditions. Lungs.—Percussion of the lungs generally bears reference to a change in density, which is only to be detected by comparing the healthy with the morbid portions. The great practical rule here to be followed is, to apply the pleximeter with the same firmness, and exactly in the same 54 EXAMINATION OF THE PATIENT situation, to each side of the chest in succession, and to let the blow with the hammer be given with an equal force. Care must be taken that the position of both arms be alike, as the contraction of the pectoral muscles on one side more than on the other may induce error. In short, every cir- cumstance must be the same before it is possible to determine, in delicate Fig. 26. Fig. 27. cases, either from the tone or sense of resistance, whether change of den- sity exist in the lungs. When circumscribed alterations are discovered in the pulmonary tissue, their limits may be marked out on the surface of the skin, in the manner previously indicated. In this way I have fre- quently succeeded in determining with accuracy the size and form of cir- cumscribed indurations, arising from partial pneumonia and pulmonary apoplexy. Under the clavicles, the pleximeter must be applied with great firmness. Inferiorly, a thin layer of lung lies over the superior surface of the liver; and to determine the exact place where its inferior border terminates, the blows with the hammer should be very slight. Posteriorly, also, the pleximeter must be firmly applied, and the force of the blows considerable; but they should decrease in force inferiorly, where a thin layer of lung descends over the liver much deeper than anteriorly. In a healthy state, a distinct difference may be observed in the sonoriety of the lungs immediately after a full expiration and a full in- spiration. This does not take place when the tissue becomes indurated from any cause ; and thus we are furnished with a valuable diagnostic sign. Congestion of the lung, and pneumonia in its first stage, cause Fig. 26, Anterior, and Fig. 27, posterior view of the normal limits and intensity of dulness on percussion. P, pulmonal sound ; C, cardiac sound; H, hepatic sound; S, splenic sound; G, gastric sound (here the stomach is moderately distended with air); E, enteric sound. In the anterior view the intestines are tolerably free from air, except CO, colic sound, from distended colon. The descending colon and rectum are filled, and sound dull. HU, humoral soimd, over a distended bladder; M, mus- cular, and 0, osteal sounds.—(Piorry.) BY PERCUSSION. 55 Fig. 28. only slight dulness and increased resistance, which, however, may occa- sionally be detected by the practised percussor. In the second and third stage of pneumonia, and in apoplexy of the lung, this dulness and resistance are well marked, and even an impres- sion of hardness and solidity commu- nicated to the hand. When, however, the lung is infiltrated with tubercle, the induration is most intense, and the greatest degree of resistance commu- nicated. Partial indurations from apoplexy or simple cancerous and tubercular ex- udation, may be detected by percus- sion, even when deep-seated and cov- ered by healthy portions of the lungs. In this case, by pressing with the plex- imeter, and striking lightly, a tympan- itic sound only is heard; but by press- ing the pleximeter down firmly, and striking with force, the dull sound may be elicited and circumscribed. When indurations, however, exist in- feriorly in those portions of the lungs which overlap the liver, it requires great practice to detect them with certainty. Caverns in the lungs, when large and filled with air, induce a tympanitic sound (Fig. 28, 3); but they are generally more or less full of viscous and fluid matters, and give rise to dulness. Two or three ounces of fluid may be detected in the pleural cavity, by causing the patient to sit up. The height or level of the fluid is readily determined, and should be marked daily by a line made with nitrate of silver. If the effusion be only on one side, the increased dul- ness is more easily detected. It disappears on placing the patient in such a position as will cause the fluid to accumulate in another part of the pleural cavity, when the space which was previously dull becomes clear (Fig. 29). When the effusion entirely fills the pleural cavity, no limit, of course, can be detected ; but, even then, the dulness is distin- guished from that of the liver by the diminished feeling of resistance. When the lung is emphysematous, or if air be present in the pleura, the sound becomes unusually tympanitic ; this tympanitic note on per- cussion, however, may exist under a variety of circumstances, which it is of great importance to be acquainted with. Thus, condensation from pneumonia at the posterior part of the lung, or partial pleurisy, by caus- ing the anterior portion of the organ to be over-distended with air, or compressed and pushed forward, may give origin to this sound. The same occurs in chronic phthisis, over parts which were once dull, either Fig. 28. Phthisis—Atrophied heart and liver—Prolonged abstinence. 1, Atrophied heart; 2, Infiltrated tubercle on left side; 3, the same on right side with a cavity; 4, Atrophied liver; 5, Spleen; 6, unusual dulness over abdomen, from prolonged absti- nence.—(Piorry.) 56 EXAMINATION OF THE PATIENT from large dry cavities filled with air, or from the emphysema which accompanies cicatrices and partial condensation of pulmonary texture. On percussing the chest with the mouth open, there may frequently be elicited a sound, which Laennec first likened to gently striking a cracked pot. It may be very closely imitated by crossing the palms of both hands, so as to leave a hollow between them, and then striking the knuckles of the inferior hand against the knee, so as to produce a clinking sound. I have produced it by percussing the chest in cases of pleurisy, pneumonia, and phthisis; of congested, apoplectic, and emphy- sematous lungs, and even when these organs were quite healthy, if, as in young subjects, the ribs are very elastic. The conditions which seem favorable for the production of this sound are, 1st, A certain amount of confined air rendering the tissue of the lung tense; 2d, The sudden corn- Fig. 29. pression of this air by a solid body in its neighborhood; 3d, Communication of this air with the external atmosphere. Hence it is not diagnostic of any particular disorder, or pathological state, such as a pulmonary cavity, so much as of a physical condition, which, however, if rightly interpreted, is likely to be of the utmost advantage in our efforts at detecting the nature of diseases.* Heart.—To mark out the precise limits of the heart constitutes the first difficult lesson in the art of percussion. M. Piorry commences by determining the clear sound at the upper end of the sternum, and bring- ing the pleximeter gradually downwards till the dull sound of the heart be heard. I have found it best to place the instrument first under and a little inside the left nipple, where the cardiac dulness is most intense; then to carry it upwards, striking it continually with the hammer until the clear sound of the lung be elicited; then by bringing it down again towards the heart, we shall readily distinguish the line where cardial dulness commences, and thus limit the superior margin of the organ. The same method is to be followed in determining the situation of the lateral margins, only carrying the pleximeter outwards or inwards, strik- ing more and more forcibly with the hammer, until the clear tympanitic sound of the lung only be heard. It is more difficult to determine the * See the author's " Clinical Investigation into the diagnostic value of the cracked- pot sound."—Edinburgh Medical Journal for March, 1856. Fig. 29. Pleurisy. 1, On the right side when in the erect position; 2, On the left side, when lying on the right; 3, Kidneys, the left enlarged ; 4, Spleen.— (Piorry.) BY PERCUSSION. 57 situation of the apex of the heart; for as this rests on the diaphragm, and this again upon the left lobe of the liver, it cannot readily be distin- guished from them. The size of the heart, however, may be pretty accurately estimated, by limiting its superior and lateral margins. In females, the left mammary gland should be drawn upwards and out- wards by an assistant. In the natural position of the organ (Figs. 1 and 2) it is well to remember that the auri- cles are on the right, and the ventri- cles on the left side. The normal size of the heart differs in different persons. As a general rule, however, it may be considered that, if the transverse diameter of the dulness measure more than two inches, it is abnormally enlarged. It has been known to measure seven inches. (Pi- orry.) In hydropericardium, the dul- ness has been remarked to exist rather at the superior part of the sternum, than on one side or the other. (Pior- ry, Reynaud.) In pericarditis it bulges out inferiorly (Fig. 30, 1). In Fig. 30. hypertrophy and dilatation of the right auricle, the increased extent of the dulness stretches toward the median line, and sometimes passes over it (Fig. 31, 3). In similar hypertrophy of the left ventricle, the dulness extpnds on the left side more or less, according to the increased size of the heart (Fig. 31, 1, and Fig. 32). In concentric hypertrophy there is little or no enlargement, but the density is greatly increased. The presence of tubercle in the lungs surrounding the heart; aneu- risms or other tumors pressing upon, or in the neighborhood of, the organ ; hypertrophied liver, extensive empyema, etc., etc., may render the mensuration of the extent of its dulness difficult or impossible. The changes in position of the heart produced by a pleurisy on one side push- ing it towards the opposite one, or by the pregnant uterus, or an ovarian tumor or ascites thrusting it upwards, may also be determined by per- cussion, especially if the impulse can be distinguished by palpation or auscultation. Liver.—Limitation of the size of the liver should be commenced by placing the pleximeter over the organ on the right side, where the dul- ness and resistance are greatest. It should then be carried upwards un- til the clear sound of the lung be distinguished, when it ought again to be brought down and the limit marked. This limit, however, may indi- cate either the inferior margin of the lung, or superior convex surface of the liver. Now as a thin layer of lung descends in front of the liver, it will be Fig. 30. Pericarditis, pneumonia, and loaded rectum. 1, Pericarditis; 2, Pneu- monia separable from the extreme dulness of the liver ; 3, Loaded rectum.—(Piorry.) 58 EXAMINATION OF THE PATIENT necessary to determine where the tympanitic sound ceases inferiorly, by striking gently with the hammer, and where the parenchymatous sound ceases superiorly, by striking forcibly, so that vibrations may be commu- nicated to the organ through the layer of lung. The space between these two lines thus marked on the surface is wider in some individuals than in others, and deeper and more extensive posteriorly, than anteriorly. By carrying the pleximeter from the right side anteriorly, and then pos- teriorly towards the left of the patient, the whole superior margin may be thus detected, and marked with ink upon the surface, except where the liver comes in contact, through the medium of the diaphragm, with the apex of the heart. The inferior margin is for the most part readily de- tected. It must be remembered, however, that in the same manner as a thin layer of lung covers the upper margin, so a thin layer of liver de- scends on the right side over the intes- tine. It is, therefore, necessary to be cautious in determining the inferior margins, for a tolerably strong blow with a hammer may give rise to a tym- panitic sound from the intestine, heard through the liver. The lower margin must be percussed in an inverse man- ner to the superior, and as we proceed downwards, the force of the blow should be diminished. The inferior margin of the liver is in general readily detected, from the contrast which) on percussion, its dulness and density pre- Fis- 31- ' sent, contrasted with the tympanitic and elastic feel of the intestines and stomach. The superior limit of this organ is generally found about two inches below the right nipple, at a point corresponding with the fifth rib. Its inferior border descends to the lower margin of the ribs. The extent of the jecoral dulness in the healthy state is in general two inches on the left side, three inches in the hepatic region anteriorly, and four inches in the hepatic region laterally. (Piorry.) Variations in the size of the liver, from congestion, inflammation, abscesses, hydatids, tumors, atrophy, etc., etc., may often be exactly de- termined by means of percussion. In icterus, the increase and diminu- tion of this organ, as evinced by lines marked on the skin, will generally be found to bear a proportion to the intensity of organic disease. When tumors are present, the inferior border often presents an irregular form. If the inferior lobes of the lung be indurated by tubercles or hepatisation, it becomes difficult or impossible to draw the limit between them and the liver. When fluid effusion exists in the pleura, the increased density of ♦•ii^5'*!?1' hypertrophy of liver and heart. 1, Hypertrophied liver, which may be still further enlarged to the dotted hues over the abdomen; 2, Distended gall-bladder • 3, Hypertrophied right auricle—1, Hypertrophied ventricles; 4, Loaded coecum: 5, Loaded rectum and descending colon.—(Piorry.) ' BY PERCUSSION. 59 the liver may still serve to distinguish it, and by changing the position of the patient, its upper edge in the majority of cases may be limited. In cases of ascites, we must lay the patient on the left side in order to measure the right lobe—on the right side to measure the left lobe, and on the abdomen to percuss it posteriorly. Sometimes the right lobe of the liver is so enormously hypertrophied, that its inferior margin extends to the right iliac fossa (Fig. 32). When the gall-bladder is much distended with bile, or contains gall- stones to any amount, it may readily be detected by percussion, and the dulness it occasions immediately un- der the inferior margin of the liver, anteriorly and somewhat laterally, may be marked off (Fig. 31, 2). Spleen.—In percussing the spleen, it is necessary that the patient lie on the right Fis- 32- side, and it is advantageous that the examination be made before, rather than after, meals. Anteriorly the sonoriety of the stomach and intestines causes the margin readily to be distinguished. Posterior- ly, however, where the organ approaches towards the kidneys, this is more difficult. Its superior and inferior margins may be made out by striking the instrument with some force, and following the rule (No. 10) previously given, p. 53. This organ offers great resistance on percussion. In health the spleen never projects below the false ribs, even during a deep inspiration. Its general size is about four inches long and three inches wide. (Piorry.) In diseased states it may be atrophied or enlarged. I have seen it measure upwards of twelve inches long and eight wide, and it then may project upwards and downwards, as indicated by the dotted lines in Fig. 33. A pleu- ritic effusion, ascites, pneumonia, or tubercular de- position in the inferior lobe of the left lung, may of this organ difficult or impossible. If the Fig. 33 render a limitation Fig. 32. Hypertrophied liver and spleen in leucocythemia—Enlarged heart. 1, Hypertrophied heart with dilatation; 2, Great dulness over the larger part of abdomen from enlarged liver on the right side; and enlarged spleen on the left.—(Partly from Piorry.) Fig. 33. 1, Slightly enlarged spleen, pushed somewhat upwards. The dotted lines indicate how the organ may be enlarged in various diseases. 7, Elongation downwards in leucocythemia.—(Slightly modified from Piorry.) 60 EXAMINATION OF THE PATIENT dulness cannot be detected, we may infer that its dimensions are small. (Mailliot.) Stomach and Intestines.—The sounds elicited by percussion of the stomach and intestines are of the greatest service to the practitioner:— 1st, As furnishing him with the means of determining the form of other organs, as the liver, spleen, or bladder; 2dly, As enabling him to dis- tinguish the presence or absence of faecal or alimentary matter; and, 3dly, As the means of diagnosing abdominal tumors. Hence it is in- cumbent on every physician to be able at once to recognise the differ- ence between the tones furnished by the stomach, small and large intes- tines, under various circumstances. To arrive at this knowledge, it is necessary to be acquainted with the relative positions of the different abdominal viscera, and the regions of the abdomen to which they corre- spond. For instance, it is usually the liver and not the stomach that occupies the so-called epigastric region just below the end of the ster- num. The last-named organ is for the most part situated within the left lower costal walls, just below the heart and the base of the left lung. (Figs. 1 and 2.) In exploring the abdomen by means of percussion, the pleximeter should first be placed immediately below the xiphoid cartilage, pressed firmly down, and carried along the median line towards the pubes, strik- ing it all the way, now hard, now gently, with the hammer. The differ- ent tones which the stomach, colon, and small intestines furnish, will thus be distinctly heard. The pleximeter should then be carried late- rally, alternately to the one side, and then to the other, till the whole surface be percussed. In this manner the different tones produced by the ccecum and ascending colon on the right side, as well as by the stomach and descending colon on the left, will be respectively distinguished from that furnished by the small intestines. The sounds and sense of resist- ance will be modified according as the different viscera are full or empty, as any one can determine on his own body by means of the pleximeter and hammer. When the intestines are full of fluid or solid contents, such portions may be circumscribed and marked out on the surface of the skin. I have thus often succeeded in determining the internal margin of the colon, in its ascending, transverse, or descending portions. Sometimes a portion of intestine is found lying between the abdominal walls and the stomach. The latter, however, may be readily limited, by pressing down the pleximeter, causing the patient to eat or drink, or by examining after dinner. The small intestines rarely ever fail to yield a tympanitic sound—a circumstance by which they may readily be dis- tinguished from the stomach and large intestines. The distance of any particular knuckle of intestine from the abdominal walls may be pretty accurately calculated by the force necessary to be employed in pressing down the pleximeter, and striking with the hammer, in order to elicit a tympanitic or dull sound. It is unnecessary to point out the numerous circumstances, and morbid conditions, in which percussion of the abdomen may prove useful in practice. Displacements and variations in size of the stomach or intestines, femoral and scrotal hernia, mesenteric, ovarian, and other BY PERCUSSION. 61 tumors, peritoneal adhesions and effusions, may all frequently be di- agnosed, and their limits determined, by a careful examination with the pleximeter and hammer. By means of percussion, even the nature of the tumor may often be arrived at; as, for instance, whether it be fungus hematodes, scirrhous, encysted, osseous, etc., by the different degrees of resistance they possess. Care, however, must be taken not to confound with tumors an enlarged spleen or liver, a distended uterus or bladder, stomach full of alimentary matter, etc. It should also be remembered that when the patient lies on his back the percussion sound over the stomach is resonant, but when he stands it is generally dull from the gravitation of the food. In a practical point of view it is often useful to determine, by means of percussion, whether an enema or a pur- gative by the mouth is likely to open the bowels most rapidly. If, for instance, there be dulness in the left iliac fossa, in the track of the descending colon, that part of the intestine must be full of faeces, and an enema is indicated. If, on the other hand, the left iliac fossa sound tympanitic, and the right sound dull, an enema is of little service, as it will not extend to the ccecum, and purgatives by the mouth are indicated (Figs. 30 and 31). Effusion of fluid into the peritone- um may be determined with great ex- actitude by means of percussion, and the height of the fluid marked, as in the case of pleuritic effusion. In the same manner, a change of po- sition furnishes similar results. Abdominal distension from accumulation of air may also be determined. If it be within the intestine, the tym- panitic note is partial and limited, if in the peritoneal cavity more equa- ble and diffused (Fig. 34). Kidneys.—To percuss the kidneys, the patient should lie on the abdomen and chest; a position which allows any ascitic fluid that may be present to gravitate downwards, whilst the intestines float upwards. The dulness and great resistance offered by the renal organs are, under such circumstances, at once determined (Figs. 27 and 29). Their external margins may for the most be easily limited, in consequence of the loud tympanitic note of the intestines, which can be elicited round their external circumference in the two flanks. Internally the dulness merges into that of the spinal column. Enlargement of one or both of these organs from calculous or scrofulous nephritis, pyelitis, or other Fig. 34. Dropsy of the abdomen, enlarged heart, and aneurism. 1, Aneurism pro- jecting from the arch of the aorta on the right side; 2, Hypertrophied heart, es- pecially of the right auricle ; 3, Liver, pushed upwards; 4, Ascitic fluid, gravitating inferiorly, the patient being on the back; 5 and 6, Stomach and intestines, superiorly and anteriorly.—(Piorry.) 62 EXAMINATION OF THE PATIENT diseases, may in this manner be made out, as seen (Fig. 29) on the left side. Atrophy of these organs is more difficult to determine with ex- actitude, but may be demonstrated by careful percussion. Bladder.—This viscus is only to be detected by percussion, when it is more or less distended, and rises above the pubes. It may then be dis- tinguished, and its circular margin limited, by observing the tympanitic sound of the intestines, on the one hand, and the dull sound furnished by the bladder, with increased resistance on the other. When covered by intestines, it will be necessary to press down the pleximeter with tolerable firmness, but not in such a manner as to give the patient pain. In the infant, the situation of the bladder is not so deep in the pelvis, and a small quantity of fluid renders it cognizable by means of percussion. A ready approximation of the state of the bladder will be found of great service in cases of fever, apoplexy, delirium, imbecility, paraplegia, etc. etc. In several cases it has been found dangerously distended, on percussing the abdomen to determine the state of the intestines. I have here only noticed those circumstances in the art of percus- sion which may be readily accomplished, and which every one may master in a few months by care and attention. For a description of the more delicate points, such as percussion of the foetus in utero, accurately limiting the auricles and ventricles, determining and marking Fig. 35. Fig. 36. out the ascending and transverse portions of the arch of the aorta, etc., I must refer you to the admirable works of MM. Piorry* and Mailliot.t * De la Percussion Mediate, etc., Paris, 1828. Du Procede Operatcire, Paris 1831. De l'Examen Plessimetrique de l'Aorte Ascendante, et de la Crosse Aortique etc. Archives Gen. de Med., vol. ix., 1940, p. 431. On Percussion of the Uterus, and its Results in the Diagnosis of Pregnancy: Monthly Journal, 1846-7, p. 857. Atlas de Plessimetrisme, Paris, 1851. f Mailliot (L.) Traite de la Percussion Mediate, etc., Paris ; translated into English, with notes, by Dr. George Smith of Madras. Figs. 35 and 36. Anterior and Posterior outlines of the trunk, for marking more readily the results of Percussion and Auscultation. BY AUSCULTATION. 63 A very convenient method of recording the results of percussion, consists in filling in an outline of the trunk, with pencil, so as to mark, by different shading, the intensity or extent of the dulness. With this view I have caused the small outlines of the trunk, anteriorly and pos- teriorly, here figured, to be printed in sheets, which are gummed at the back. They can in this way be kept in the pocket of your note-book, and easily attached to the paper when required. The same outlines will serve to mark the position of sounds heard in the chest, when the upper part of the outline only may be used.* AUSCULTATION. The object of auscultation is to ascertain and appreciate the nature of the various sounds which occur in the interior of the body. It has been found most useful when applied to the pulmonary and circulatory organs. Auscultation of the abdomen is occasionally serviceable, especially in certain cases of pregnancy, and during labor. It has also been applied to the head, although I have never been able to make out any useful results from the practice. General Rules to be followed in the Practice of Auscultation. 1. Auscultation may be practised directly by applying the ear to the part, or indirectly through the medium of a stethoscope. Generally speaking, direct auscultation answers every necessary purpose except when the surface is unequal, or when it is desirable to limit the sounds Fig. 37. Fig. 38. Fig. 39. Fig. 40. Fig. 41. to a small region, as during auscultation of the heart. In either of these * These sheets may be obtained of Mr. Thin, bookseller, South Bridge. Figs. 37 and 38. Stethoscopes with different sized trumpet extremities, the smaller one for auscultating the heart, or emaciated subjects. Fig. 39. Stethoscope capable of being shortened, by screwing one half into the other. Fig. 40. Stethoscope invented under the notion that its form would facilitate the conduction of sound. Fig. 41. Stethoscope invented under the idea that the spiral form, like that of a shell, would increase the intensity of sound. 64 EXAMINATION OF THE PATIENT cases a stethoscope is necessary. The instrument is also useful to confirm or nullify the existence of certain finer sounds which may be detected by the naked ear; to remove the head of the practitioner a respectable distance from the bodies of persons not distinguished for cleanliness; and lastly, as the most delicate method of auscultating the chest anteriorly in women. You should regard the stethoscope merely as a means to an end—that end being the right appreciation of the pathological changes indicated by certain sounds. 2. In the choice of a stethoscope, you should observe, 1st, That the ear-piece fits your own ear; 2d, That the trumpet- shaped extremity is not above an inch and a half in diameter, and is rounded so as not to injure the patient's skin when pressure is made upon it; 3d, That it is light and portable. The instruments recently made of gutta pereha fulfil all these condi- tions. The forms of stethoscopes vary infinitely: those represented (Figs. 37 to 39) are the most convenient, that having the smaller trumpet-shaped end being best for emaciated subjects, or for limiting the sounds F'g- 42. Fig. 43. of the heart. Figs. 40 and 41 are two stethoscopes which were presented Fig. 44. to me by two students, both of whom imagined that the form they had given tbe instruments intensified the sound. This result, however, is unquestionably attained by the double stethoscope of Canman (Fig. 43) and the differential stethoscope of Scott Alison (Fig. 44). In many Fig. 42. Flexible stethoseope. Fig. 43. Canman's stethoscope. Fig. 44. Differential stethoscope of Dr. Scott Alison. BY AUSCULTATION. 65 cases, where sounds were doubtful with the ordinary instruments, they have been rendered at once appreciable and positive by the differential stethoscope. Dr. Scott Alison also found that water enclosed in a flat circular bag of caoutchouc, still farther increased the sound, when flexible stethoscopes were employed, and I have satisfied myself, that when with these instruments no sound (friction or crepitation) is audible, they are at once rendered so by employing this bag or hydrophone (Fig. 45). Although these flexible stethoscopes have hitherto seldom been used, I have frequently, during the last four or five years, met with cases in which the differential instrument of Dr. Scott Alison has been of great service.* 3. In applying the ear, the body of the patient should be covered only with a smooth piece of linen or a towel. But the stethoscope should be applied to the naked skin, and held steady immediately above the trumpet-shaped extremity by the thumb and index finger; it should be pressed down with tolerable firmness, whilst with the second, third, and fourth fingers, you ascertain whether the circular edge be perfectly applied, which- is abso- lutely essential. 4. The position of the patient will vary according to the part examined. In auscultating the lungs anteriorly, the erect or recumbent positions may be chosen, the Fig. 45. two arms being placed in a symmetrical position by the side. If the chest be examined posteriorly, the individual should lean somewhat forward and cross the arm3 in front. In auscultation of the abdomen, various positions will be required, according as the anterior, lateral, or posterior regions demand investigation. The practitioner, also, should choose such a position as will prevent too much stooping or straining. Generally speaking, the beds in the Infirmary here are too low, and ren- der auscultation very fatiguing to the physician. In young children or infants we should place our ears on their backs. 5. Whenever individuals are thrown into such a state of agitation as to interfere with the regular action of the heart or lungs, the examina- tion should be deferred until their fear diminishes, or the greatest cau- tion should be exercised in drawing conclusions. Non-attention to this rule has led to many errors. 6. Before examining patients in a hospital, it is necessary that you should have made yourselves perfectly acquainted with the sounds which are continually going on in the healthy body. Omission of this rule * See hig valuable work, " The Physical Examination of the Chest in Pulmonary Consumption, etc." London, 1861. Fig. 45. The Hydrophone of Dr. Scott Alison. 5 Go EXAMINATION OF THE PATIENT not only renders the examination of patients useless, but betrays great want of consideration. For, as it is only from the alterations the healthy sounds undergo, or from their being replaced by others, that we draw conclusions, how can this be accomplished if we are ignorant of their character in the first instance ? It is expected, therefore, of every ex- amining pupil, that he should be familiar with the character and theory of the various sounds heard in the healthy body before coming to the bed-side. This study belongs to the Institutes of Medicine, rather than to that of Clinical Instruction. Special Rules to be followed during Auscultation of the Pulmonary Organs. 1. In listening to the sounds produced by the action of the lungs, we should pay attention to three things : 1st, The natural respiration; 2d, The forced or exaggerated respiration ; and 3d, The vocal resonance. For this purpose, having listened to the sounds during ordinary breath- ing, we direct the patient to take a deep breath, and then, still listening, we ask him a question, and during his reply judge of the vocal re- sonance. 2. You should commence the examination immediately under the centre of one clavicle; and having ascertained the nature of the sounds and vocal resonance there, you should immediately listen at exactly the corresponding spot on the opposite side. The examination should be continued alternately from one side to the other, in corresponding places, until the whole anterior surface of the chest is explored. The posterior surface is then to be examined in like manner. 3. When in the course of the examination, anything different from the normal condition is discovered at a particular place, that place and the parts adjacent should be made the subject of special examination, until all the facts regarding the lesion be ascertained. 4. It is occasionally useful to tell the patient to cough, in which case we are enabled to judge,—1st, Of forced inspiration, as it precedes the cough; and 2d, Of the resonance which the cough itself occasions. Of the Sounds produced by the Pulmonary Organs in Health and in Disease. I am anxious to impress upon you, that the sounds which may be heard in the lungs are like nothing but themselves. Students are too apt to take up erroneous notions from reading on this subject, and, instead of listening to the sound actually produced, fatigue themselves in a vain endeavor to hear something like the crackling of salt, the rubbing of hair, foaming of beer, or other noises to which these sounds have been likened. Preconceived notions frequently oppose themselves to the reception of the truth, and have to be got rid of before the real state of matters can be ascertained. Hence the great importance of deriving your first impressions of the sounds to be heard by auscultation, not from books or lectures, but from the living body itself. If you listen through your stethoscope, placed over the larynx and BY AUSCULTATION. 67 trachea of a healthy man, you will hear two noises—one accompanying the act of inspiration, and the other that of expiration. These are called the laryngeal and tracheal sounds or murmurs. If you next place your stethoscope a little to the right or left of the manubrium of the sternum, you will hear the same sounds diminished in intensity. These are the bronchial sounds or murmurs. If now you listen under and outside the nipple on the right side, or posteriorly over the inferior lobe of either lung, you will hear two very fine murmurs. That accom- panying the inspiration is much more distinct than that accompanying the expiration. By some, on account of its excessive fineness, it is stated that there is no expiratory murmur in health; but this is incor- rect. These sounds, then, are the vesicular respiratory murmurs. All these sounds become exaggerated during forced respiration, but in a state of health they never lose their soft character. Again, if you listen in the same places, whilst the individual speaks, you will hear a peculiar resonance of the voice, which has been called, in the first situation, pectoriloquy; in the second bronchophony; while in the third it is scarcely audible. A knowledge of these circumstances, and a capability of appreciating these sounds, are necessary preliminary steps to the right comprehension and detection of the murmurs which may be heard during disease. I have to suppose, then, that you have made your ears familiar with these sounds, and that you are acquainted with the present state of theory regarding their formation. This last may be stated in very few words to be, that the respiratory murmurs are occasioned by the vibra- tion of the tubes through which the air rushes, according to the well- known acoustic principles. Hence they are loudest in the trachea, finer in the large bronchi, and finest in their ultimate ramifications. The vocal resonance, on the other hand, originates in the larnyx; and diminishes or increases—1st, According to the distance of any point from the source of the sound ; and, 2d, According to the power which textures have in propagating it. If now you examine, in succession, any six of the cases in the wards which are laboring under well-marked pulmonary diseases, you will have no difficulty in recognising that all the sounds you hear may be classified into two divisions : 1st, Alterations of the natural sounds; 2d, New, cr abnormal sounds, never heard during health. I. Alterations of the Natural Sounds.—All the sounds of which we have spoken, and which can be heard in the lungs during health, may, in certain diseased conditions, be increased, diminished, or absent; their character or position may be changed ; and with regard to the respiratory murmurs, they may present alterations in rhythm or duration with respect to each other. Alterations in Intensity.—Some persons have naturally louder respiratory murmurs than others; if this occur uniformly on both sides, it is a healthy condition. Occasionally, however, the sounds are evi- dently stronger at one place, or on one side (puerile respiration), and then they generally indicate increased action of the lung, supplementary to diminished action in some other part. In the same manner, there 68 EXAMINATION OF THE PATIENT may be feeble respiration simply from diminished action, as in feeble or old persons; but it may also be occasioned by pleurodynia, obstructions in the larnyx, trachea, or bronchi—pleurisy, or pulmonary emphysema, or exudations filling up a greater or less number of the air-cells and smaller tubes, as in pneumonia, phthisis, etc. Complete absence of respiration occurs where there is extensive pleuritic effusion or hydro- thorax. Alterations in Character.—The various respiratory murmurs may, in certain conditions of the lung, assume a peculiar harshness, which, to the ear of the practised auscultator, is a valuable sign, indicative of altered texture. Thus, in incipient phthisis, the vesicular murmur under the clavicle is often rude or harsh. In pneumonia the bronchial or tubular respiratory murmur presents a similar character. When a cavity is formed, it becomes what is called cavernous (hoarse or blowing); and in certain cases of pneumothorax with pulmonary fistula, it assumes an amphoric character. Alterations in Position.—It frequently happens that the sounds which are natural in certain parts of the chest are heard distinctly at places where in health they are never detected. Thus, in pneumonia, bronchial, or tubular breathing, as it is sometimes called, may be evident, where only a vesicular murmur ought to exist. This is often well marked with re- gard to the vocal resonance, as certain lesions, which occasion condensa- tion or ulceration of the lungs, will enable us to hear either broncho- phony or pectoriloquy, where, under ordinary circumstances, no voice can be heard. Alterations in Rhythm.—In health, the inspiration is usually three times as long as the expiration. In certain diseased conditions this rela- tion is altered, or even inverted. In incipient phthisis we often find the expiration unnaturally prolonged. In chronic bronchitis and emphysema it is three or four times longer than the inspiration. II. New or Abnormal Sounds.—These are of three kinds : 1st, Rub- bing or friction sounds; 2d, Moist rattles ; 3d, Vibrating murmurs. 1. Rubbing or Friction Sounds are caused in the pulmonary apparatus by some morbid change in the pleurae, whereby, instead of sliding noise- lessly on one another, they emit a rubbing sound. This may be so fine as to resemble the rustling of the softest silk, or so coarse as to sound like the creaking of a saddle, grating, rasping, etc.; and between these two extremes you may have every intermediate shade of friction noise. This variation in sound is dependent on the nature of the alteration which the pleurae have undergone. If covered with a softened thin exu- dation, the murmur will be soft; if it be tougher and thicker, the sound will be louder; if hard, dense, and rough, it will assume a creaking, harsh, or grating character. These noises are heard in the various forms of pleurisy. 2. Moist Rattles are produced by bubbles of air traversing or breaking in a somewhat viscous fluid. This may occur in the bronchi, when they contain liquid exudation, mucus or pus, or in ulcers of various sizes. They may be so fine as to be scarcely audible (when they have been called crepitating), or so coarse as to resemble gurgling or splashing, when BY AUSCULTATION. 69 they have received the name of cavernous. Here, again, between these two extremes, we may have every kind of gradation, to which auscultators have attached names, such as, mucous, submucous, subcrepitating, etc. etc. With these names you need not trouble yourselves; all that it is impor- tant for you to determine is, whether or not the sound be moist, and you will easily recognise that the rattles are coarse or large, in proportion to the size of the tubes or ulcers in which they are produced, and the amount of fluid present. These rattles may be heard in pneumonia, phthisis pulmonalis, bronchitis, pulmonary apoplexy, etc. etc. 3. Dry Vibrating Murmurs arise when the air-tubes are obstructed, constricted, or lose their elasticity and become enlarged, whereby the vibrations into which they are thrown by the column of air produce sounds or tones of an abnormal character. Hence murmurs may be occasioned of a fine squeaking (sibilous murmur), or of a hoarse snoring character (sonorous murmur), and between the two extremes, there may be all kinds of variations, to which ingenious people have applied names. These only cause confusion; all that is necessary is to ascertain that the murmur is dry, and you will readily understand that the fineness or coarseness of the sound will depend on the calibre of the tube or cavity thrown into vibrations. They are usually heard in cases of bronchitis and emphysema. Occasionally they present a blowing character, as when ulcers are dry, a condition which often occurs in phthisis. The vocal resonance, besides undergoing the changes already noticed in intensity, character, and position, may give rise to abnormal sounds. Occasionally it presents a soft reverberating or trembling noise, like the bleating of a goat (ozgophony). The value of this sign, as indicative of pleurisy, was much overrated by Laennec. At present it is little esteemed. Sometimes the resonance gives rise to a metafflc tinkling, a noise similar to that caused by dropping a shot into a large metallic basin, or the note produced by rubbing a wet finger' round the edge of a tumbler or glass vessel. This is often best heard immediately after a cough in certain cases of chronic phthisis. -ZEgophony is supposed to be produced when a thin layer of serous fluid between the pleurae is thrown into vibrations. The cause of metallic tinkling has created great dis- cussion, and is not yet ascertained. Such, then, are the principal sounds which may be heard on auscul- tation of the pulmonary organs in health and during disease. Many writers have endeavored to point out their diagnostic importance, and drawn up rule3 which have always appeared to me much too arbitrary. Indeed, in so far as the education of medical students is concerned, I have long been persuaded that the study of these rules has retarded their powers of diagnosis, and afterwards led to dangerous errors in practice. I know of no dogma, for instance, more mischievous than the one which asserts a crepitating (that is, a fine moist) rattle to be pathognomonic of pneumonia, because such a rattle is just as common in phthisis, and is frequently heard in various other lesions of the pulmonary organs. Hence we should regard a crepitating rattle, not as distinctive of this or that so-called disease, but simply of fluid in the smaller air-passages; so also an increased resonance of the voice, as indicating hollow spaces with 70 EXAMINATION OF THE PATIENT vibrating walls, or increased induration of the pulmonary textures, and not as diagnostic of phthisis, pneumonia, and so on. I wish, then, strongly to impress upon you,— 1st, That the different sounds are only indicative of certain physical conditions of the lung, and in themselves bear no fixed relation to the so-called diseases of systematic writers. 2d, No single acoustic sign, or combination of signs, is invariably pathognomonic of any certain pathological state,—and conversely, there is no pathological state which is invariably accompanied by any series of physical signs. 3d, Auscultation is only one of the means whereby we can arrive at a just diagnosis, and should never be depended on alone. (See intro- duction to diseases of the respiratory system.) Special Rules to be followed during Auscultation of the Circulatory Organs. 1. In listening to the sounds produced by the action of the heart and arteries, we should pay attention—1st, To the impulse; 2d, To the character and rhythm of the sounds; 3d, To the place where they are heard loudest, and the direction in which they are propagated.* 2. You should commence the examination by feeling for the spot where the apex of the heart beats against the walls of the chest, which will enable you to judge of the impulse. This ascertained, place your stethoscope immediately over it, and listen to the sounds. Then place the instrument above, and a little to the inside of, the nipple, near the margin of the sternum, and listen to the sounds there. In the one situa- tion you will hear the first or systolic sound, in the other the second or diastolic sound louder. 3. If anything different from the normal condition be discovered in either one or the other position, or in both, this should be again care- fully examined, and by moving the stethoscope below and round the apex of the heart, or above, in the course of the aortic arch or carotids, on the right and left side, etc. etc., it should be ascertained at what point, or over what space, the abnormal sounds are heard loudest, and whether they be or be not propagated in the course of the large vessels. Occasion- ally listening over the back and in the course of the descending aorta may be useful. 4. When, during the above examination, we discover a new source of impulse or of sound in one of the large vessels, this must be especially examined, the limits of such impulse and sound carefully ascertained— whether it be or be not synchronous with those originating in the heart —its direction, etc. 5. Under ordinary circumstances, the respiratory do not interfere with * The numerous instruments recently invented for rendering observations on the impulse of the heart and on the pulse more accurate should not be overlooked. Among these are the sphygmoscopes of Scott Alison, the sphygmosphone of Upham, and the sphygmographs of Vierodt, Marey, and Czermack. They have not yet been used much at the bed-side, although the smaller one of Marey, made by Breguet of Paris, admits of ready application whenever a particularly accurate observation is required. BY AUSCULTATION. 71 the detection of the cardiac sounds ; but where the former are very loud and the latter indistinct, it is useful to direct the individual to hold his breath for a few moments. Sometimes the impulse and sounds of the heart are heard better by directing the patient to lean forward; they may also, if necessary, be exaggerated and rendered more distinct by di- recting him to walk quickly, or to make some exertion for a short time. Of the Sounds produced by the Circulatory Organs in Health and Disease. On placing your ear over the cardiac region in a healthy person, you will feel a beating, and hear two sounds, which have been likened to the tic-tac of a watch, but to which they bear no resemblance. They may be imitated, however, very nearly, as pointed out by Dr. Williams, by pronouncing in succession the syllables lupp, di/pp. The first of these sounds, which is dull, deep, and more prolonged than the second, coin- cides with the shock of the apex of the heart against the thorax, and immediately precedes the radial pulse; it has its maximum intensity over the apex of the heart—below and somewhat to the inside of the nipple. The second sound, which is sharper, shorter, and more super- ficial, has its maximum intensity nearly on a level with the third rib, and a little above and to the right of the nipple—near the left edge of the sternum. These sounds, therefore, in addition to the terms first and second, have also been called inferior and superior, long and short, dull and sharp, systolic and diastolic—which expressions, so far as giving a name is concerned, are synonymous. The two sounds are repeated in couples, which, if we commence with the first one, follow each other with their intervening pauses thus—1st, There is the long dull sound coinciding with the shock of the heart; 2d, There is a short pause; 3d, The short sharp sound; and 4th, a longer pause, all which correspond with one*pulsation. In figures, the duration of these sounds and pauses by some has been represented thus,—the first sound occupies a third, the short pause a sixth, the second sound a sixth, and the long pause a third. Others have divided the whole period into four parts; of which the two first are occupied by the first sound, the third by the second sound, and the fourth by the pause. The duration, as well as the loudness, of the sounds, however, are very variable, even in health, and are influenced by the force and rapidity of the heart's action, individual peculiarity, and form of the thorax. Their extent also differs greatly. They are generally distinctly heard at the precordial region, and diminish in proportion as we withdraw the ear from it. They are less audible anteriorly on the right side, and still less so pos- teriorly on the left side. On the right side posteriorly they cannot be heard. Their tone also varies in different persons; but in health they are free from a harsh or blowing character. Great diversity of opinion has existed regarding the causes of these sounds—which you will have heard discussed before coming here. You must never forget, however, the cardiac actions which coincide with them; for our reasoning from any changes we may detect in the sounds will entirely depend upon our knowledge of these coincidences. We may 72 EXAMINATION OF THE PATIENT consider, then, that there occur with the first sound—1st, The impulse, or striking of the apex against the thoracic walls; 2d, Contraction of the ventricles; 3d, Rushing of the blood through the aortic orifices; and 4th, Flapping together of the auriculo-ventricular valves. There coincide with the second sound—1st, Rushing of the blood through the auriculo-ven- tricular valves; and 2d, Flapping together of the aortic valves. Contrac- tion of the auricles immediately precedes that of the ventricles. The result of numerous pathological observations, and of many experiments, is, that in health the first sound is produced by the combined action of the auriculo-ventricular valves, of the ventricles, and of the rushing of the blood, which sound is augmented in intensity by the impulsion of the heart's apex against the thorax ; whereas the second sound is caused only by the flapping together of the sigmoid valves. With the cardiac as with the respiratory sounds, the alterations which take place during disease may be divided into—1st, Modification of the sounds heard in health; 2d, New or abnormal sounds. I. Modifications of the Healthy Sounds.—These refer to the vari- ations the healthy sounds present in their seat, intensity, extent, character, and rhythm. Seat.—The sounds may be heard at their maximum intensity lower than at the points previously indicated, as in cases of dilated hypertro- phy of the left ventricle, enlargement of the auricles, or of tumors at the base, depressing the organ. They may be higher, owing to any kind of abdominal swelling pushing up the diaphragm. They may be more on one side or the other, in cases where' the heart is pushed laterally by effusions of air or fluid in a pleural cavity. Various other circumstances may also modify their natural position, such as tumors in the anterior or posterior mediastinum, aneurisms of the large vessels, adhesions of the pericardium, deformity in the bones of the chest, etc. etc. Intensity and extent.—These aro*diminished in cases where the heart is atrophied or softened; when there is pericardial effusion, cencentric hypertrophy of the left ventricle, or emphysema at the anterior border of the left lung. They are increased in cases of dilated hypertrophy, of ner- vous palpitations, and when neighboring portions of the lung are indu- rated, especially in certain cases of pneumonia and phthisis pulmonalis. Character.—The sounds become clearer or didler than usual, accord- ing as the walls of the heart are thinner or thicker. Occasionally they sound muffled in cases of hypertrophy or softening of the muscular walls, Not unfrequently there is a certain degree of roughness, which is difficult to determine as being healthy or morbid. Occasionally it ushers in more decided changes; at other times it continues for years without altera- tion. These alterations in character are distinguished by some auscultators as variations in the tone of the sounds. Rhythm or Time.—I need not say that the frequency of the pulsa- tions differs greatly in numerous affections altogether independent of any special disease in the heart. In certain cardiac affections, however, the beats are intermittent, in others irregular— that is, they succeed each other at unexpected intervals. The number of the sounds also varies. Some- times only one can be distinguished, it being so prolonged as to mask the BY AUSCULTATION. 73 other. Occasionally three or even four sounds may be heard, depending either on reduplication in the action of the valves when diseased, or on want of synchronism between the two sides of the heart. Not unfre- quently the increased and irregular movements of the organ, combined with the sounds, are of such a character as to receive the name of tumultuous. II. New or Abnormal Sounds.—These are of two kinds—1st, Fric- tion murmurs; 2d, Blowing or vibrating murmurs. Dr. Latham has called them exocardial and endocardial. I am in the habit of denomi- nating them pericardial and valvular. Pericardial or Friction Murmurs.—These murmurs are the same in character, and originate from the same causes as the friction noises con- nected with the pulmonary organs. It is only necessary to observe, that occasionally they are so soft as closely to resemble blowing murmurs, from which they are only to be distinguished by their superficial charac- ter and limited extent. Valvular or Vibrating Murmurs.—These murmurs vary greatly in character; some being so soft as to resemble the passage of the gentlest wind ; others are like the blowing or puff from the nozzle of a bellows (bellows murmurs) ; whilst others are harsher, resembling the noise pro- duced by grating, filing, sawing, etc. They are all occasioned, however, by diseases interfering with the functions of the valves. Sometimes these do not close, and the blood consequently regurgitates through them; at others, whilst this is the case, they are constricted, indurated, rough- ened, and even calcareous—whence the harsher sounds. They may be single or double, and have their origin either in the auriculo-ventricular or arterial valves, or in both at once, the detection of which constitutes the diagnosis of the special diseases of the organ. Occasionally these sounds resemble musical notes, more or less resembling the cooing of a dove, singing or twittering of certain small birds, whistling, tinkling, etc. etc. These depend either upon excessive narrowing of the orifices, or upon any causes which induce vibrations of solids in the current of blood —as, when there are perforations in the valves, irregularities of their margins, string-like or other shaped exudations on their surface, etc. etc. Auscultation of the Abdomen. On applying the stethoscope over the stomach and intestines in a healthy state, various gurgling and churning noises may be heard. In the former they may assume an amphoric or metallic character, in the latter they are called borborygmi. They are caused by the displace- ments of gas and water, and are most audible during the period of digestion, and the action of a purgative or enema. The impulse of the aorta can be detected especially in thin subjects, when the pressure of the stethoscope may often be made to elicit a blowing sound. In disease these sounds may be increased or diminished, and in addition, there may be present various kinds of friction or grating sounds when the surface of the peritoneum is roughened, owing to exudation or the unequal pressure of tumors. These last may also give rise to 74 EXAMINATION OF THE PATIENT. blowing murmurs, when it often becomes difficult to determine whether the morbid sound originates in the tumor itself, or is the result of the pressure it exercises on the aorta. In cases of doubtful pregnancy, the marked rapidity of the foetal pulse contrasted with that of the individual examined, constitutes a positive sign. Auscultation of the Large Vessels. On listening through the stethoscope placed over the arteries in the neighborhood of the heart, we hear the same sounds as are produced at the sigmoid valves, propagated along its course, but more indistinctly as we remove the instrument away from the base of the heart. In those which are more distant only one sound, which is synchronous with their impulse and their dilatation, is heard. This sound is of a dull character, but in health always soft. In the various conditions of disease we have a single or a double bel- lows sound, or it may be harsh, grating, rasping, etc. In the first place, you must ascertain whether any of these sounds are propagated along the artery from the heart, and this you will learn by listening over its course from that organ, and by observing whether they.increase as you proceed towards it. If the sound have an independent origin, it may originate from disease of the internal surface of the artery, when it will be harsh in proportion to the roughness; from stricture of, or pressure on the vessel, or from its dilatation. Generally speaking, the more dilated and superficially seated the vessel is, the sharper is the sound. Sometimes there is a double murmur in the course of a vessel, having an undoubtedly independent origin. This is most common in cases where there is an aneurismal pouch, into which the blood passes in and out through an opening narrower than the swelling itself. Occasionally one or both such murmurs may possess somewhat of a metallic ringing, or even musical character, and in such case the margins of the opening are probably tense, and thrown into peculiar vibrations. * Not unfrequently a soft systolic blowing is audible at the base of the heart, or over the carotids and deep jugular vein. At other times it is continuous, resembling humming, or the noise of a Parisian toy called le diable. These murmurs are distinguished from valvular ones—1st, By being systolic at the base of the heart; 2d, By their softness; 3d, By not being permanent; and 4th, By occurring in anaemic or debili- tated persons, and especially in young girls. I have already told you never to form a conclusion as to the nature of the disease from auscultation alone. Even when combined with per- cussion, it is not safe to form a diagnosis without a knowledge of all the circumstances of the case. Hence why I repudiate those rules which have been published in books, that have for their object the establish- ment of opinions from physical signs alone. At the same time, there can be no doubt that percussion and auscultation are absolutely essential to the proper investigation of maladies, although not more so than other modes of inquiry. I have, therefore, thought it best to give you a con- densed resume of the sounds which may be heard by auscultation of the USE OF THE MICROSCOPE. 75 lungs, heart, abdomen, and large vessels; pointing out a few of the diseased states in which they may be sometimes (not always) heard, and especially indicating the physical conditions on which they are supposed to depend. Their true diagnostic value can only be learned by the careful examination of individual cases. I strongly advise you not to complicate your practical study of this important subject with certain speculative problems, as to the seat of sounds originating in the tricuspid valve and pulmonary artery. Careful examinations have con- vinced me that these latter sounds in the vast majority of cases cannot be separated from those originating in the left side of the heart, and that all diagnosis based upon their supposed existence in fixed areas of the pericardial region must be fallacious. (See introduction to diseases of the circulatory system.) USE OF THE MICROSCOPE. A knowledge of the ultimate structure of the human body, in its healthy and diseased conditions, is now so advanced as to necessitate the introduction of the microscope among the ordinary instruments of the medical practitioner. But you must not suppose that an additional method of gaining information implies abandonment of those, the utility of which has stood the test of experience. Men must learn the every- day use of their senses; must know how to feel, hear, and see in the same manner as they did before instruments were invented. We don't see the stars less clearly with our naked sight, because the telescope is necessary for an astronomer. Neither should a physician observe the symptoms of a disease less accurately because he examines the chest with a stethoscope, or a surgeon be less dexterous with the knife, be- cause it is only by means of the microscope he can determine with exactitude the nature of a tumor. But it is unnecessary to enter into a lengthened argument to prove that the science and art of medicine are greatly indebted, in modern times, to the invention and proper applica- tion of ingenious instruments. The following examples will serve to convince you that the microscope is one of these:— Example 1.—Some years ago I was summoned to see a Dispensary patient laboring under bronchitis, who was spitting florid blood. On examining the sputum with a microscope, I found that the colored blood corpuscles were those of a bird. On my telling her she had mixed a bird's blood with the expectoration, her astonishment was unbounded, and she confessed that she had done so for the purpose of imposition. Example 2.—A gentleman, for some years, had labored, under a variety of anomalous symptoms, referable to the head and digestive systems, under which he had become greatly reduced. He had con- sulted many practitioners, and visited innumerable watering-places, in a vain search after health. On examining the urine with a microscope, I found it crowded with spermatozoa. He evidently labored under spermatorrhoea, a disease which had never been suspected, but which was readily cured on the employment of an appropriate treatment. Example 3.—A boy was brought to me with an eruption on the 76 EXAMINATION OF THE PATIENT. scalp, which was of so indefinite a character that its nature could not be determined. He had lately been elected to occupy a vacancy in one of our charitable educational establishments, and the question to decide was, whether the disease was or was not contagious. On examining the scab with a microscope, I readily discovered the Achorion Schoenleini, or fungus constituting true favus; and as this has been experimentally proved to be inoculable, I had no hesitation in preventing his admission to the school. Example 4.—A child was supposed to be affected with worms, because it passed in abundance yellowish shreds, which, to the naked eye, closely resembled ascarides. All kinds of vermifuge remedies had been tried in vain. On examining the shreds with a microscope, I found them to consist of undigested spiral vessels of plants ; and they ceased to appear when the vegetable broth used as food was abandoned. Example 5.—I was called to see an infant, a month old, which was in a state of considerable emaciation, with constant diarrhoea. The mother, however, maintained that her milk was abundant, and that it was taken in sufficient quantity. On being examined with a microscope, it was found to contain numerous compound granular bodies, and compara- tively few milk globules. In short, it presented, in an exaggerated de- gree, all the characters of colostrum, and this thirty days after delivery. It was evident, then, that the quality of the milk was in fault, an opinion which was confirmed by the recovery of the infant, when a healthy nurse was procured. Example 6.—An individual was supposed to be laboring under dysentery, from the frequent passage of yellowish pulpy masses in the stools, accompanied with tormina and other symptoms. On examining these masses with the microscope, I found them to consist of undigested potato skins. On inquiry, it was ascertained that this person had eaten the skins with the potatoes. On causing these to be removed before dinner, the alarming appearance ceased, and the other symptoms also disappeared. Example 7.—An elderly lady conceived herself to be affected with insects continually forming in the skin, which produced incessant itching and tingling. All the hair was removed, and every kind of application, including mercurial preparations, was tried without effect. On rubbing the surface, she always saw minute white rolls and black specks, which she regarded as insects in different stages of development. The torment and anxiety this caused her for many months it is scarcely possible to conceive. At length she labored under the idea that she was communi- cating^the disease to her husband and daughter, when, at the request of her medical attendant in the west of Scotland, she came to Edinburgh in order that I might investigate and treat it. I had the pleasure of showing this lady, under the microscope, that the white bodies were minute rolls of epidermis or of the cotton cloth with which she rubbed the skin, and that the black specks were portions of dust or soot. Her hallu- cination being in this way dissipated, she returned home perfectly well. Example 8.—A child had been suffering for four years from copious and foetid discharge from the nostrils, accompanied with great oain. At the end of that time, a dark brown and indurated mass was discharged about an inch long, and a quarter of an inch broad, closely resembling a USE OF THE MICROSCOPE. 77 sequestrum of bone. This mass I was requested to examine microscopi- cally by Dr. Littlejohn, under whose care the patient was, and from its structure I readily determined that it consisted of some fir wood. When this was known, the parents remembered that, about the time the disease commenced, alterations were made in the house, and that the children used to play with the wood shavings. There could be little doubt that a piece of shaving had been thrust up the nose, and been the cause of all the symptoms. Examples of this kind could be readily multiplied. No doubt mis- takes will be made with this instrument in the hands of inexperienced persons, in the same manner as the use of the stethoscope, or of a scalpel, may lead to false conclusion, or to an accident. But this, so far from being an argument opposed to their employment, only proves the necessity of becoming more skilful in their use. Certainly there is no instrument which requires more expert management in itself, or more caution in drawing conclusions from its employment, than the microscope. Description of the Microscope. It is not my intention to enter upon a description of the optical principles on which microscopes are constructed, although you will find a knowledge of these very useful. I shall suppose that you are desirous of obtaining an instrument that will answer all the purposes of the anato- mist and physiologist, as well as afford you every possible assistance in the way of diagnosis as medical men. For this purpose, you should learn to dis- tinguish what is necessary from what is unnecessary, in order that you may procure the former in as convenient a form, and at as moderate a cost as possible. A microscope may be divided into mechanical and optical parts. The former determine its general form and appearance. Of the numerous models which have been invented, the one here figured, exactly one-fourth its real size, appears to me the most useful for all the purposes of the physiologist and medical practitioner. The body consists of a telescope tube, eight inches in length, held by a split tube, thr„e inches long. It may be Fig. 46. Oberhaeuser's model, made at my suggestion for medical men, l-4th the real size. This instrument may be procured at M. O.'s manufactory, Place Dau- phine, Paris, or at Mr. Young's, cutler, North Bridge, and Mr. Kemp's, Infirmary Street, Edinburgh. 459385 78 EXAMINATION OF THE PATIENT. elevated and depressed with great readiness by a cork-screw movement, communicated to it by the hand, and this constitutes the coarse adjust- ment. It is attached to a cross-bar and pillar, at the lower portion of which last, very conveniently placed for the hand of the observer, is the fine adjustment. The stage is three inches broad, and two and a half inches deep, strong and solid, with a circular diaphragm below it. The base of the instrument is heavily loaded with lead to give it the neces- sary steadiness. This form of microscope possesses all the mechanical qualities re- quired in such an instrument. These are—1st Steadiness; 2d, Power of easy adjustment; 3d, Facility for observation and demonstration; and, 4th, Portability. 1. Steadiness.—It must be evident that if the stage of the microscope is subject to any sensible vibration, minute objects, when magnified highly, so far from being stationary, may be thrown altogether out of the field of view. Nothing contributes more to the comfort of an observer than this quality of a microscope, and great pains have been taken to produce it. In the large London instruments this end has been admir- ably attained, but at so much cost and increase of bulk as to 'render it almost useless. In the small model I have recommended, all the steadi- ness required is present in the most convenient form. 2. Power of Easy Adjustment.—It is a matter of great importance to those who use the instrument much, and work with it for hours together, that the adjustments should work easily and rapidly, and be placed in convenient situations. Nothing can be more commodious than the manner in which these ends are arrived at in the model figured. By insertion of the body of the instrument within a split tube, you may, by a spiral movement, elevate and depress it with the greatest rapidity, and even remove it altogether if necessary. The necessity of con- tinually turning the large screws affixed to most microscopes becomes fatiguing in the extreme. Then the fine adjustment, placed conveniently behind the microscope, near the hand which rests on the table, is in the very best position ; whereas, in some London instruments, it is placed on the top of the pillar, so that you must raise your hand and.arm every time it is touched. In other London instruments, it is placed in front of the body, so that you must stretch out the arm and twist the wrist to get at it. No one could work long with so inconvenient a contrivance. 3. Facility for Observation and Demonstration.—For facility of observation and demonstration, it is necessary that the instrument should be of a convenient height, and that the stage on which the objects are placed should be easily accessible. Here, again, nothing can be more commodious than the microscope I have recommended, for when it is placed on a table, its height is almost on a level with the eye, and we can look through it for hours without the slightest fatigue. On the other hand, the stage is elevated, just so much as enables the two hands, resting on their external edges, to manipulate with facility all kinds of objects placed upon it. The large London instruments are so high as to render it necessary to stand up to see through them. To obviate this disadvantage, a movement is given to the body, by which it can be depressed to any angle. But this movement renders the stage oblique, USE OF THE MICROSCOPE. 79 and removes it to a distance, where it becomes very inconvenient to manipulate on its surface. To obviate this difficulty, the stage itself has been rendered movable in various ways by different screws, so that in this way complexity has been added to complexity, until a mass of brass work and screws is accumulated, to the advantage of the optician, but to the perplexity and fatigue of the observer. But by no contrivance is it possible to avoid the aching arms which such a position of the stage invariably produces in those who work with such a cumbrous machine for any length of time. 4. Portability.—This is a property which should by no means be overlooked in instruments that are intended more for utility than orna- ment. A medical man is often called upon to verify facts in various places; at his own house, at an hospital, at the bed-side of his patient, or at a private post-mortem examination. It is under such circum- stances that the value of portability is recognised. The large London instruments require an equipage or a porter to transport them from place to place; even the putting them in and out the large boxes or cabinets that are built around them, is a matter of labor. In short, notwith- standing the splendor of the screws, the glittering of the brass, and the fine workmanship, there can be little doubt that, on the whole, they are very clumsy affairs. There are many occasions on which a medical man may find it useful to carry a microscope with him, especially in the case of post-mortem examinations. Many attempts have been made to construct a pocket microscope; and for the purposes above alluded to, I myself caused one to be made some years ago, which, with its case, resembled a small pocket telescope. Dr. Gruby of Paris, however, has planned the most ingenious instru- ment of this kind, which possesses most of the prop- erties we have enumerated, and will be found very use- ful for those accustomed to microscopic manipulation. It is contained in a case, the size of an ordinary snuff-box, and possesses all the conveniences of the larger instruments, with various lenses, a microm- eter, slips of glass, needle, knife, and forceps, in that small com- pass. Figures 47 and 48, representing the instrument, exactly one- half the real size, will give an idea of this ingenious microscope, manufactured by the late M. Bruuner of Paris. For a more minute description of it, I must refer you to the " Monthly Journal of Medical Science" for December 1846. Equally commodious pocket microscopes, but on a somewhat different model, are now made by Nachet. Fig. 47. Gruby's compound pocket microscope—exactly one-half the real size. 80 EXAMINATION OF THE PATIENT. There is a general feeling among the public that the larger a micro- scope is, the more it must magnify; but I need not tell you this is error. A very imposing mass of brass work and mechanical complexity is no guarantee that you will see objects better, or, what is of more consequence, become good observers. On the contrary, the more unwieldy the in- strument, the less disposed will you be to use it. Besides, the habitual employment of artificial methods of moving about the object, as by the screws of a movable stage, will prevent your acquiring that dexterous use of your fingers and accuracy of manipulation which are at all times so useful. Nothing, indeed, can be more amusing than to see a man twisting his screws, pushing his heavy awkward stage about, and laboriously wasting time to find a minute object which another can do in a moment, and without fatigue, by the simple use of his fingers. But perhaps you will consider the weightiest objection to the large instru- ments is the expense they necessitate,—the cost being necessarily in pro- portion to the amount of brass and mechanical labor employed upon Fig. 48. Fig. 49. them. If, then, you have to choose between a complex model and a simple one, I strongly advise you as a matter of real economy, to choose the latter. Indeed the former, to a practical histologist, is worthless. I have found the clinical microscope of Dr. Beale (Fig. 49) very useful at the bedside, as it allows the object to be passed from hand to hand of the students attending. It consists of a split tube, with a widened extremity, having a spring and screw which firmly fixes the object glass. The focus is obtained by lengthening or shortening the tube, as with a telescope. I have made a slight modification in it, which admits of the application of a diaphragm. The extra tube can be had separately, so that any of you who possess an Oberhaeuser's microscope can apply it to the body Fig. 48. Gruby's pocket microscope mounted, ready for use—half the real size. Fig. 49. Beale's clinical microscope—one-fourth the real size. USE OF THE MICROSCOPE. 81 of that instrument, and thus, at a* moderate expense, convert it into a clinical and pocket microscope. We have next to speak of the optical parts of microscopes, which are certainly much more important than the mechanical ones—for everything depends upon obtaining a clear and distinct image of the object examined. Under this head we may describe the objective, the eye-piece, and methods of illumination. 1. The objective, or series of Achromatic Lenses, is that part of the optical portion of a microscope which is placed at the bottom of the tube or body, and is near the object to be examined. This may be considered the most important part of the instrument, and the greatest pains have been taken by all opticians in the manufacture of good lenses. It is here I consider that the London opticians are pre-eminent, for I am not aware that in any part of the world such perfect objectives have been manufactured as the eighth of an inch by Smith, the twelfth of an inch by Ross, and the sixteenth of an inch by Powell. But when we come down to the one-fourth of an inch, which is by far the most useful objec- tive for anatomical and medical purposes, the superiority of the London opticians is very slight, if any. At this magnifying power the compound lenses of Oberhaeuser, and Nachet of Paris; Schiek and Pistor of Berlin; Frauenhofer of Munich, and Ploesl of Vienna may be em- ployed with the greatest confidence, and it may be said that by far the largest number of important discoveries in science have been made through their employment. The Parisian lenses, in addition, have one great advantage, namely, their cheapness. The London opticians have succeeded in combining the lenses of their objectives,^ so as to obtain a large field of vision with as little loss of light as possible. These qualities are valuable in the lower magnify- ing lenses during the examination of opaque objects, and in the higher ones when observing transparent objects by transmitted light. But in the lenses of medium power, such as the one-fourth of an inch, the amount of light is so great as to be almost a defect. Notwithstanding careful management of the mirror and diaphragm, the field of vision is often dazzling, and always presents a glare most detrimental to the eyes of the observer. I cannot employ Ross's fourth of an inch for fifteen minutes without feeling intense headache, and I know of more than one excellent observer in whom the sight has so much suffered from this cause as to incapacitate them from continuing their researches. In the same manner, certain French lenses give rise to a yellow light highly disagreeable; while those of Oberhaeuser, Schiek and Pistor, and Frauen- hofer (with Amici's and Ploesl's I am not familiar), present a pale blue light, most pleasant to work with, and which may be gazed at for hours without fatiguing the eye. For the above reasons, as well as from considerable experience in the use of many kinds of microscopes by different manufacturers, I am satisfied that the best lens you can employ for ordinary purposes is Oberhaeuser's No. 7, which corresponds to what is called in England the quarter of an inch. For low powers you may have Oberhaeuser's No. 3, or the one-inch lens of the London opticians. For all the wants of the medical man these will be sufficient. The anatomist may occasionally 6 82 EXAMINATION OF THE PATIENT. require a higher lens, as during the examination of the ultimate fibrillae of muscle, when the eighth, twelfth, or sixteenth of an inch of the London opticians may be procured. All these lenses may be attached to the model we have recommended by means of a brass screw made on purpose. . 2. The Eyepiece.—This is that portion of the optical apparatus which is placed at the upper end of the tube or body, and is near the eye of the observer. While the objective magnifies the object itself, the eye-piece only magnifies the image transmitted from below. Hence, as a source of magnifying power, it is inferior to the lens; and when this possesses any defects, these are enlarged by the eye-piece. Two eye- pieces are all that is necessary with the model I have recommended, and those of Oberhaeuser, called Nos. 3 and 4, are the most useful for the medical man. 3. Methods of Illumination.—There are few things of more import- ance to the practical histologist than the mode of illumination. This is accomplished—1st, By transmitted light; 2d, By reflected light; and 3d, By achromatic light. Transmitted light i3 obtained by means of a mirror placed below the object, which, to be seen, must therefore be transparent. In large microscopes the mirrors are provided with universal joints, so that they may easily be turned in any direction. Below the stage every micro- scope should possess a diaphragm pierced with variously sized holes, whereby the amount of light furnished by the mirror may be moderated. In Oberhaeuser's and Nachet's instruments the smallest aperture should be employed for the higher objective. It is also useful in the examina- tion of many objects that the light should be directed upon them side- ways ; this may be done by the diaphragm, or by the mirror, and in the small model formerly figured (Fig. 46), is admirably attained by simply ^ turning the whole microscope. The best light for microscopic purposes is that obtained by catching the rays which are reflected from a white cloud. The conjoined use of the mirror and diaphragm can only he learned from actual experience. Reflected light is employed in the examination of opaque objects. . The lenses of low power, manufactured by the principal London opticians, enable us to do this without assistance. Occasionally, however, the light of the sun is useful; and when this cannot be obtained, the rays of a lamp or gas light, concentrated by a bull's eye lens, may be employed. Hence every microscope should be possessed of such a lens, and it is most convenient to have it attached to the body of the instrument by a movable ring, and stem with two joints, as in the model figured (Fig. 46). Achromatic light is only serviceable in the examination of very delicate objects, with high powers. The apparatus necessary for obtain- ing it is occasionally useful in ascertaining the ultimate structure of muscle, or the nature of the markings on minute scales or fossils, but is useless for the purposes of the medical man. In the same way I know of no benefit to be obtained by a polarising apparatus. In addition to the mechanical and optical parts constituting the microscope itself, the box which contains it should possess a convenient place for holding a few slips of glass, a pair of small forceps, a knife, and USE OF THE MICROSCOPE. 83 two needles firmly set in handles. A micrometer to measure objects with is also essential to those who are making observations with a view to their exact description. No other accessories are necessary. An excellent microscope of the model previously figured, by Ober- haeuser (Pig. 46), with two objectives (Nos. 3 and 7), two eye-pieces (Nos. 3 and 4), a neat box with all the accessories necessary (with the exception of a micrometer, which had better be English), may be ob- tained in Paris for the sum of about 150 franca (£6), and are sold in Edinburgh by Mr. Young, cutler, North Bridge, for £6 :15s. Nachet's instruments are much cheaper, as are the smaller models of Oberhaeuser. Either of them, for all the purposes of the medical man, is amply suffi- cient. Test- Objects.—The defining power of a microscope is generally tested by examining with it a transparent object, having certain fine markings, which can only be rendered clearly visible when the glasses are good. In all such cases, it is of course necessary to be familiar with the structure of the test-object in the first instance. If you are not confident on this point, it is better to trust to the judgment of a friend, whose knowledge of histology is ascertained, or place your dependence entirely on a respect- able optician. One of the best test-objects for a quarter of an inch lens is a drop of saliva from the mouth. For, if the microscope shows with clearness the epithelial scales, the structure of the salivary globules, their nuclei, and contained molecules, you may be satisfied that the instrument will exhibit all the facts with which, as medical men, you have to do— (See Fig. 51). Mensuration and Demonstration. Having, then, obtained a good instrument, and tested its qualities in the manner described, you should next determine the number of dia- meters linear the various combinations of glasses magnify. This you may do for yourself with the aid of a micrometer, a pair of compasses, and a measure. A micrometer is a piece of glass on which lines are ruled at the dis- tance of T£oth or TTr'-0-7th of an inch. This must be placed under the instrument, when the lines and the distances between them will of course be magnified by the combination of glasses employed, like any other object. Taking a pair of compasses in one hand, we separate the points, and place them on the stage (always on a level with the micrometer magnified). Now, looking through the instrument with one eye, we regard the points of the compasses with the other, and mark off by the naked sight, say the -r^th of an inch, as magnified by the instrument. Though difficult at first, a little practice enables us to do this with the greatest accuracy. The result is, that if the distance magnified and so marked off (Ti„th of an inch) is equal to three inches, the instrument magnifies 300 times linear; if two inches, 200 times; and so on. To measure the size of objects, they may be placed directly on the micrometer; but as this is at all times inconvenient, whilst the object and micrometer, from their not being in the same plane, cannot, under high powers, both be brought into focus at once, it is better to use an eye- micrometer. Many ingenious inventions of this kind are to be procured. 84 EXAMINATION OF THE PATIENT. The most simple is a ruled micrometer placed in the focus of the upper glass of the eye-piece. With this we observe how many divisions of the eye-micrometer correspond with one of those magnified by the microscope, always making our observation in the centre of the field, where the aberration of sphericity is least. On the latter being removed and re- placed by an object, it becomes a matter of mere calculation to determine its size. Thus, supposing each of the upper spaces in Fig. 50 to repre- sent the x^o otn of an mcn magnified 250 diameters linear, and five of the lower spaces, as seen in an eye-micrometer, to correspond with one Fi"-. 50. 0I" these—it follows that each of these latter must measure ^oVotn °f an incn> Oberhaeuser has made beautifully ruled eye-micrometers, for the model re- commended (Fig. 46), which those who wish to make measurements would do well to procure. If it be not in your power to estimate the magnifying power for yourself, the optician will give you a table, setting forth the various degrees Spaces equal toi-ioooth .of of enlargement possessed by the lenses, and different an inch magnified 2o0 dia- . ° . ,r J mi. , ,, meters linecr. eye-pieces, with the tube up or down. Ihis table should always be referred to during the description , i of objects, and the amount of magnifying power invariably stated. I The art of demonstrating under the microscope ' is only to be acquired by long practice, and, like Five ruled spaces in an eye-every thins: requiring practical skill, cannot be learnt micrometer, corresponding - r 1 ± ±- t t i to oue of those above, and from books or systematic lectures. I can only, thTiffihora^ Sive y°u vei7 general directions on this head. All that is necessary in examining fluid substances is to place a drop in the centre of a slip of glass, and letting a smaller and thinner piece of glass fall gently upon it, so as to exclude air bubbles, place it upon the stage under the objective. In this way the fluid substance will be diffused equally over a flat surface, and evaporation prevented, which would dim the objective. The illumination must now be carefully arranged, and the focus obtained, first by means of the coarse, and then by means of the fine adjustment. It will save much time, in examining structures, to employ always, at one sitting, the same slips of glass, as it is easier to clean these with a towel, after dipping them in water, then to be perpe- tually shifting the coarse adjustment. The action of water, acetic acid, and of other re-agents, on the particles contained in a fluid, may be observed by mixing with it a drop of the re-agent before covering with the upper glass; or if this be already done, the drop of re-agent may be placed at the edge of the upper glass, when it will be diffused through the fluid under examination by imbibition. The mode of demonstrating solid substances will vary according as they are soft or hard, cellular or fibrous. The structure of a soft tissue, such as the kidney, skin, cartilage, etc., is determined by making very minute, thin, and transparent slices of it in various directions, by .means of a sharp knife or razor. These sections should be laid upon a slip of glass, then covered over, and slightly pressed flat, by means of an upper USE OF THE MICROSCOPE. 85 one. The addition of a drop of water renders the parts more clear, and facilitates the examination, although it should never be forgotten that most cell-structures are thereby enlarged or altered in shape from endos- mosis. Acid and other re-agents may be applied in like manner. The double-bladed knife of Valentin will enable you to obtain large, thin, and equable sections of such tissues, and permit you to see the manner in which the various elements they contain are arranged with regard to each other. Harder tissues, such as wood, horn, indurated cuticle, etc., may also be examined after making thin sections of them. Very dense tissues, such as bone, teeth, shell, etc., require to be cut into thin sections and afterwards ground down to the necessary thinness. Preparations of this kind are now manufactured on a large scale, and may be obtained at a trifling cost. A cellular parenchymatous structure, such as the liver, may be examined by crushing a minute portion between two glasses. If it be membranous, as the cuticle of plants, epithelial layers, etc., the membrane should be carefully laid flat upon the lower glass, and covered with an upper one. A fibrous structure, such as the areolar, elastic, muscular, and nervous tissues, must be separated by means of needles, and then spread out into a thin layer before examination, with or with- out water, etc. The commencing observer should not be discouraged by the difficulties he will have to encounter in dissecting and displaying many tissues. He must remember that the figures he sees published in books are generally either fortunate or very carefully prepared specimens. Practice will soon enable him to obtain the necessary dexterity, and to convince himself of the importance of this mode of inquiry. He should early learn to draw the various objects he sees, before and after the action of re-agents, not only because such copies constitute the best notes he can keep, but because drawing necessitates a more careful and accurate examination of the objects themselves. A note-book and pencil for the purpose should be the invariable accompaniments of every microscope. How to Observe with a Microscope. The art of observation is at all times difficult, but is especially so with a microscope, which presents us with forms and structures concern- ing which we had no previous idea. Rigid and exact investigation, there- fore, should be methodically cultivated from the first, in order to avoid those errors into which the tyro, when using a microscope, is particularly liable to fall. Thus, you should carefully examine the physical properties of the particles and ultimate structures you may see, and not hastily con- clude that you have under observation so-called pus, tubercle, or cancer- corpuscles, because they were obtained from what was, a priori, believed to be pus, tubercle, or cancer. Nothing has been more clearly demon- strated by the progress of histology, than the fact, that the naked sight has confounded different structures together, from a similarity of external appearance, and that the greatest caution is required at all times, but especially by learners, in forming opinions as to the nature of different tissues. The physical characters which distinguish microscopic objects consist 86 EXAMINATION OF THE PATIENT. of—1st, Shape; 2d, Color; 3d, Edge or border; 4th, Size; 5th, Trans- parency; 6th, Surface; 7th, Contents; and 8th, Effects of re-agents. These we may notice in succession. 1. Shape.—Accurate observation of the shape of bodies is very neces- sary, as many of these are distinguished by this physical property. Thus the human blood globules, presenting a biconcave round disk, are in this respect different from the oval corpuscles of the camelidae, of birds, reptiles, and fishes. The distinction between circular and globular is very necessary to be attended to. Human blood corpuscles are circular and flat, but they become globular on the addition of water. Minute structures seen under the microscope may also be likened to the shape of well-known objects, such as that of a pear, balloon, kidney, heart, etc. etc. 2. Color.—The color of structures varies greatly, and often differs, under the microscope, from what was previously conceived regarding them. Thus the colored corpuscles of the blood, though commonly called red, are in point of fact yellow. Many objects present different colors, according to the mode of illumination—that is, as the light is reflected from, or transmitted through their substance, as in the case of certain scales of insects, feathers of birds, etc. Color is often produced, modified, or lost by re-agents, as when iodine comes in contact with starch corpuscles, when nitric acid is added to the granules of chlorophyle, or chlorine water affects the pigment cells of the choroid, and so on. 3. Edge or Border.—The edge or border may present peculiarities which are worthy of notice. Thus, it may be dark and abrupt on the field of the microscope, or so fine as to be scarcely visible. It may be smooth, irregular, serrated, beaded, etc. etc. 4. Size.—The size of the minute bodies, fibres, or tubes, which are found in the various textures of animals, can only be determined with exactitude by actual measurement, in the manner formerly described. It will be observed, for the most part, that these minute structures vary in diameter, so that when their medium size cannot be determined, the variations in size from the smaller to the larger should be stated. Human blood globules in a state of health have a pretty general medium size, and these may consequently be taken as a standard with advantage, and bodies may be described as being two, three, or more times larger than this structure. 5. Transparency.—This visible property varies greatly in the ulti- mate elements of numerous textures. Some corpuscles are quite dia- phanous, others are more or less opaque. The opacity may depend upon corrugation or irregularities on the external surface, or upon contents of different kinds. Some bodies are so opaque as to prevent the transmis- sion of the rays of light, when they look black by transmitted light, although they be white, seen by reflected light. Others, such as fatty particles and oil globules, refract the rays of light strongly, and present a peculiar luminous appearance. 6. Surface.—Many textures, especially laminated ones, present a dif- ferent structure on the surface from that which exists below. If, then, in the demonstration, these have not been separated, the focal point must be changed by means of the fine adjustment. In this way the capillaries in the web of the frog's foot may seem to be covered with an epidermic USE OF THE MICROSCOPE. 87 layer, and the cuticle of certain minute fungi or infusoria to possess peculiar markings. Not unfrequently the fracture of such structures enables us, on examining the broken edge, to distinguish the difference in structure between the surface and the deeper layer of the tissue under examination. 7. Contents.—The contents of those structures, which consist of envelopes, as cells, or of various kinds of tubes, are very important. These may consist of included cells or nuclei, granules of different kinds, pigment matter, or crystals. Occasionally their contents present definite moving currents, as in the cells of some vegetables, or trembling rotatory molecular movements, as in the ordinary globules of saliva in the mouth. 8. Effects of Re-agents.—These are most important in determining the structure and chemical composition of numerous tissues. Indeed, in the same manner that the anatomist with his knife separates the various layers of a texture he is examining, so the histologist, by the use of re- agents, determines the exact nature and composition of the minute bodies that fall under his inspection. Thus, water generally causes cell forma- tions to swell out from endosmosis; whilst syrup, gum water, and con- centrated saline solutions, cause them to collapse from exosmosis. Acetic acid possesses the valuable property of dissolving coagulated albumen, and, in consequence, renders the whole class of albuminous tissues more transparent. Thus, it operates on cell walls, causing them either to dis- solve or become so thin as to display their contents more clearly. JEther, on the other hand, and the alkalies, operate on the fatty compounds, caus- ing their solution and disappearance. The mineral acids dissolve most of the mineral constituents that are met with, so that in this way we are enabled to tell, with tolerable certainty, at all events the group of chemi- cal compounds to which any particular structure may be referred. PRINCIPAL APPLICATIONS OF THE MICROSCOPE TO DIAGNOSIS. A perfect application of the microscope, for the purpose of diagnosis, can only be arrived at by obtaining, in the first instance, a complete knowledge of the tissues of plants and animals, both in their healthy and diseased conditions. The medical practitioner may be called upon to distinguish, not only the various structures which enter in to every species of food, every kind of animal texture and fluid, and every form of morbid product, but he will frequently have to judge of these when more or less disintegrated, changed, or otherwise affected by the pro- cesses of mastication, digestion, expectoration, ulceration, putrefaction, maceration, etc. etc. In this place, however, I propose merely calling your attention to those points which are more likely to fall under your notice at the bed-side. No doubt, the practical applications of the microscope are daily extending, and whilst there are many points which may be said to be scarcely investigated, those which have been most so re- quire to be further studied. At the same time, a careful and persevering examination of the morphological elements fourd in the various excreta of the body, as modified by different diseases, or by constitution and diet, 88 EXAMINATION OF THE PATIENT. cannot but prove of great importance in the present state of practical medicine Hence, besides shortly discussing what is known, 1 shall especially indicate what are those subjects which may be elucidated by such of you as, by previous histological observations, are qualified for the task. Saliva. The readiest way of examining the saliva is to collect a drop of that fluid at the extremity of the tongue, and let it fall on the centre of a slip of glass. It should be allowed to remain quiescent for a minute or so, until most of the bubbles of air have collected in a mass on the sur- face. This should then be gently scraped off or placed aside with a needle, and the subjacent fluid covered with a thin glass. There will now be observed, with a magnifying power of 250 diameters linear— 1st, The salivary corpuscles; 2d, Epithelial scales of the mouth; 3d, Molecules and granules. 1. The salivary corpuscles are colorless spherical bodies, with smooth margins, varying in size from the ^V^th to the ygVota °f an mcn i" diameter. They contain a round nucleus, varying in size, but generally occupying a third of the cell; and between this nucleus and the cell wall are numerous molecules and granules, which communicate to the entire •«•(&>* corPuscle a finely molecular aspect. The «--'. 3$£ O ~_ • ' addition of water causes these bodies to swell " .; ' (CJ):f\'. J out and enlarge from endosmosis. Acetic acid •',S'Jf"j.-'>° ,-■? '". v'-'-s somewhat dissolves the cell wall, and it be- ''■.fsf.-f'-) %(f ; \\, comes, more transparent; while the nucleus °~',* "/c- * l: °*, '"a \ '• appears more distinct as a single, double, or f\ rj v;c'' & /_ tripartite body. Both water and acetic acid v--' [^J'Cj.-.\'>^^-' produce also coagulation of the albuminous f matter contained in the fluid of the saliva, which assumes the form of molecular fibres, in which the corpuscles and epithelial scales become entangled, and present to the naked eye a white film. 2. The Epithelial scales found in the saliva are derived from the mouth, and consist of flat plates, variously shaped, but generally pre- senting an oblong or squarish form, more or less curled up at the sides. Not unfrequently these have five or six sides, and are assembled together in groups, with their edges adherent. In size they vary from the -g}^ to the j^th of an inch in length. Embedded in their substance is a round or oval nucleus, together with numerous molecules and granules. Water produces no change in these bodies; but acetic acid renders the scale more transparent, and causes the nucleus to appear more distinct with a darker edge. 3. Associated with the salivary corpuscles and epithelial scales are several molecules and granules, which vary in number in different people, and at various times of the day. There may also be occasionally found in the saliva various foreign substances derived from the food,—such as granular debris of different kinds, starch globules cr vegetable cells, muscular fasciculi, portions of Fig. 51. Salivary corpuscles, epitbelial scales, witb molecules and granules as seen in a drop of saUva. Magnified 250 diam. linear. USE OF THE MICROSCOPE. 89 * areolar tissue, tendon, or spiral filaments, etc., derived from pieces of texture which have adhered to the teeth during mastication. The saliva may present various alterations, dependent on disease of the mucous membranes of the mouth and tongue. This, when ulcerated, causes an increase in the molecu- lar and granular matter. Many of the epithelial scales also lose their transparent character and become opaque, from an aug- mentation of granular matter in their substance. Not unfre- quently, under such circum- stances, they give rise to con- fervoid growths, which mainly spring up in the debris collected in the mouth, either on the surface of ulcers, 1.1 the sordes wnich collect on the teeth, gums, and tongue of ,l\ individuals laboring under fever, or even in the inspissated mucus of persons who sleep for a considerable time with the mouth open (Fig. 52.) In infants, the tongue and cavity of the mouth are not unfrequently covered with a yellowish flocculent matter constituting the disease named muguet by the French, in which sporules and confervoid filaments, in a high state of development, may be detected in k considerable numbers (Fig. 53). iJJ In epithelial cancroid of the tongue, the U epithelial scales exhibit a great tendency to ' split up and form fibres, and may frequently be found on the surface of the ulcer, present- ing the form here figured (Fig. 54). An histological examination of the saliva, of the fur and load of the tongue, in the great majority of diseases, is still a desideratum. Milk. On examining a drop of milk* we observe a number of bodies roll in a clear fluid. These bodies, in healthy milk, are perfectly spheri- cal, with dark margins, smooth and abrupt on the field of the microscope, with a clear transparent centre, which strongly refracts light. In size they vary in different specimens, from a point scarcely measurable up to tue 4pVota or 3oVotu 0I"an mcn m diameter. In excess of ether they are dissolved or disappear; but if this re-agent be in small quantity, cxosmosis takes placj, and the field of the microscope is covered with loose globules of oil, of various forms. Water causes the milk globules * The mode of examining all fluids is the same, and is described p. 84. Fig. 52. Minute confervoid filaments springing from an altered epithelial scale, scraped from the surface of a cancroid ulcer of the tongue (Leptothrix bucccalis). Fig. 53. Confervoid filaments and sporules, in the exudation on the mouth and gums, constituting muguet in infants. Fig 54. Fringe-like epithelium, from the surface of an ulcer on the tongue. 250 di. p.<§$>\^:. 90 EXAMINATION OF THE PATIENT. to swell out, but very slightly. Acetic acid coagulates the caseous fluid in which they swim, and causes the globules to be aggregated together in masses. Several of the globules also exhibit, under the action of this re- agent, a certain flaccidity, and readily run into one another under pressure. These globules consist of a delicate envelope of casein, enclosing a drop of oil or butter. The membrane keeps them separate, so long as it is intact; but, dissolved by means of acetic acid, or ruptured by heat or mechanical violence (as in the churn), the butter is readily separated and collected. Cream is composed of the larger of these globules, which. owing to their low specific gravity, float on the surface of milk when allowed to repose. The richness of milk is determined by the quantity of these globules. An examination of cow's and human milk will at once show that the former contains a larger number than the latter. In all efforts, however, to determine the relative value of milk by microscopic examination, great care must be taken that the drop of fluid examined should be of the same bulk, that the same upper glass should be used in every case, and that it should be applied and pressed down with the same force. It is very difficult at all times strictly to fulfil these conditions, for not only is great skill in manipulation required, but an intimate acquaintance with the appearance of milk as seen under the microscope is necessary, before any confidence can be placed in this mode of testing the quality of different specimens of the fluid. At the same time, the difference in the amount of oily constituents between the milk of the cow, ass, and human female, may in this way be easily determined. In the same manner the various adulterations of milk are at once determined. Water, of course, separates the globules more and more .-.»s®".'<|.>®$\ ©*°^^>aL',/s from each other according to its |%. ^°°^^& amount. Flour will exhibit the ip£08i larSe starch corpuscles, which are 1:6j®^''AL©« changed blue by the action of ri ' -■.V~i Art a. . _ . « ___ * _ wmm > ^PP^;^^.1|P0 iodine. Chalk shows numerous ■&M^&^' ^®S'lli^iiif^ irregular mineral particles, which are soluble in the mineral acids; Fig 55. Fig. 56. and broken-down brain will be distinguished by large oil globules, mingled with fragments of fine nerve- tubes. Milk, when acid, exhibits the same character that it does under the action of acetic acid. Healthy and fresh milk is indicated by a certain uniformity in the size of the globules; by their perfectly globular form; by their rolling freely over each other, and not collecting together in masses (Fig. 55). When the latter circumstance occurs, it is a sign of acidity. The milk first secreted after parturition is called the colostrum. It is yellow in color, and may be seen under the microscope to contain globules more variable in size, mingled with a greater or less number of granule cells (Fig. 56). These latter ought to disappear in the human female on the fifth or sixth day after parturition, but occasionally they Fig. 55. Globules of cow's milk. Fig. 56. Colostrum of the human female, containing milk globules greatly varying in size, with compound granular corpuscles. 23<> diam. USE OF THE MICROSCOPE. 91 remain, when the milk must be considered as unhealthy. ^ In some cases I have seen them abundant so late as six weeks after the infant's birth. On some occasions, milk may be mixed with pus and blood, which are readily detected by the characters distinctive cf each. Dr. Peddie has pointed out that milk can be squeezed from the mamma during the early months of pregnancy. Under such circumstances, it constitutes a most important sign of the pregnant state, especially of a first pregnancy; for although the secretion at this time has seldom the external appear- ance of milk, but is serous-looking, aud often very viscid and syrupy, still, if examined with the microscope, the characteristic milk globules will at once appear. See his valuable paper, " Monthly Journal of Medical Science," August 1848. The Blood. On examining a drop of blood drawn from the extremity of the finger by pricking it, there will be seen a multitude of yellow round bi-concave discs, rolling in the field of the microscope, which soon exhibit a tendency to turn upon their edge, and arrange themselves in rolls, like rouleaux of coins. These rouleaux, by crossing one another, dispose themselves in a kind of network, between which may be seen a few colorless spheri- cal corpuscles, having a molecular surface, and a few granules. The colored blood corpuscles, vary in size from the joVo^ to *^e 3 oVo^ 0I" an inch in diameter, their average size being about the 4oVotu or" an inch—according to Gulliver, sVooth 0I"an mcn- Owing to their bi-con- cave form, they present a bright external rim with a central shadowed spot, or a bright centre and a dark Of^« <-S V- -y ^ {'$") ;'c0 "f*r"@\ strong acetic acid the cell-wall is -r'' ,. ~ ~.J r.^-y:,--:--~'' 0'"'' ®J dissolved, and the nuclei liberated "' «**. >X£J °ML'1 if 'f\ in the form of two, three, four, or .J /^p\ •-•""••. M!?./ rarely five granules, each of which . <*" Jo.jy '"••■-•^'•---••■''''ci'i nas a centraI shadowed spot. If, ":> '^ '--'■-'' however, the re-agent be weak, Fis- c0- ri? CT- the cell-wall is merely rendered transparent and diaphanous, through which the divided nucleus is very visible. Occasionally these bodies are seen surrounded by another fine mem- brane, as in Fig. 68. At other times they are not perfectly globular, but present a more or less irregular .. ,'&-- ."'"-■- margin, and are associated with .■^ISgpa ^;/' J. ^.~fZ%J:is-;-- numerous molecules and granules. .,--- ... '^- *&', ~ 4Jt " ' This occurs in what is called scro-■ (;, - ' ;^ /""\ '•_ -' : fulous pus, and various kinds of | Q * ^ ; unhealthy discharges from wounds '--ts^' ~~ "^^/ &y'J-:& and granulating surfaces (Fig. 69). Fig. 6S. Fig. 69. In gangrenous and ichorous sores, we find a few of these irregular pus corpuscles associated with a multitude of molecules and granules, and with transformed and broken-down blood globules, the debris of the involved tissues, etc. etc. Sputum. A microscopic examination of the sputum demands a most extensive knowledge of both animal and vegetable structures. I have found in it, —1st, All the tissues which enter into the composition of the lung, such as filamentous tissue, young and old epithelial cells; blood corpuscles, etc. 2d, Mucus from the oesophagus, fauces, or mouth. 3d, Morbid growths, such as pus, pyoid, and granular cells; tubercle corpuscles, granules, and amorphous molecular matter; pigmentary deposits of various forms, and parasitic vegetations, which are occasionally found on the lining membrane of tubercular cavities. 4th, All the elements that enter into the composition of the food, whether animal or vegetable, which become attached to the mouth or teeth, and which are often mingled with the sputum, such as pieces of bone or cartilage, muscular fasciculi, portions of esculent vegetables, as turnips, carrots, cabbages, etc.; or of grain, as barley, tapioca, sago, etc.; or of bread and cakes; or of fruit, as grapes, apples, oranges, etc. All these substances render a microscopic examination of expectorated matters anything but easy to the student. To examine sputum, it should be thrown into water, when, on account of the air it contains, it will generally float on the surface; while the more dense portions, such as masses of crude tubercle or creta- Fig. 66. Pus corpuscles, as seen in healthy pus. Fig. 67. The same, after the addition of acetic acid. Fig. 68. Pus corpuscles, surrounded by a delicate cell-wall. Fig. 69. Irregular-shaped pus corpuscles, in scrofulous pus. 250 diam. USE OF THE MICROSCOPE. 95 ceous concretions, occasionally mingled with it, will fall to the bottom. It should be then teased, or broken up with a rod, when the various elements and particles it contains will gradually disengage themselves, and may be separated from the mass without difficulty. Nothing is more common, on examining portions of sputum with a microscope, than to observe the various aggregations of molecular and granular matter here figured— '%''■■M,' from the os uteri contains the former, /•>'ft.A whilst the peculiar fluid characteristic of a gonorrhoea or catarrh, in either sex, abounds *W) 0i\ (^{(iitZ~- m *ne latter. The gelatinous substance, ==r-- however, in which these bodies are found (Mucin), is what is peculiar to the fluid secreted from mucous surfaces, containing, as it does, a large amount of albumen pos- sessing a remarkable tendency to coagulate in the form of molecular fibres (Fig. 99). When recent, these are few in number, but Fig' "• on the addition of water or acetic acid they are precipitated in such numbers as to entangle the cell formations, and present a semi-opaque membranous structure (Figs. 82 and 96). The more^ healthy a mucous secretion, the more it abounds in this viscous albuminous matter, and the fewer are its cell elements. On the other hand, when altered by disease, the cell elements increase, and the viscosity diminishes. Fig. 99. Viscid greyish yellow sputa of pneumonia, treated with dilute acetic acid, containing fibrinous mucin, pus corpuscles, and epithelial cells containing fatty and pigment granules.—(fyter Wedl.) 300 diam ''h >% USE OF THE MICROSCOPE. 103 Dropsical Fluids. The fluids obtained by puncture of dropsical swellings may in some cases, when examined microscopically, present peculiarities worthy of notice. Thus, in the serum collected within the tunica vaginalis testis, numerous spermatozoids may be found, constituting what ^ < > has been called spermatocele. How these bodies find t \ their way into this fluid is unknown, as no direct com- «=—■!■—^1 munication with the substance of the testicle has ever been seen; neither does their occurrence seem to inter- fere in any way with the successful treatment of this kind of dropsy, by injections, as practised in hydrocele. In the fluid of ascites, when removed from the body, there may usually be observed a few epithelial scales from the serous layer of the abdomen, which are more abundant in some cases than in others. Occasionally blood and pus corpuscles may be detected in greater or less quantity. In ovarian dropsy, various products may be found in the evacuated fluid, according to the nature of the contents of the cyst. Pus and blood -...-r^^,-?' corpuscles are common elements, but more com- *-~ft >'^W&P>(S) monly epithelial cells and scales, which occasion- V •• 'ft, ■;, "ftft'^ ally accumulate in the cysts of ovarian tumors ftf^wvfY' V (Fig- 101). At other times, masses of gelatinous •/"T^- ° e I or colloid matter are evacuated, which present :%&' ft %,,\'~° -'•' :''°o*. various appearances, according to the time that has ft»"_li'ft ftft2"* elapsed since its formation (see Colloid Cancer 6i-J> ^S*' and Ovarian Dropsy). ^■^^■^i^f'ii^y In the examination of dropsical fluids, also, 1,'ig. xoi. there can be little doubt that further research will lead to very important results in diagnosis. Urine. Healthy human urine examined with the microscope, when recently passed, is absolutely structureless. Allgwed to repose for twelve hours, there is no precipitate; occasionally a slight cloudy deposition may be observed, in which may be discovered a few epithelial scales from the bladder, a slight sediment of granular urate of ammonia, or a few crystals of triple phosphate. In certain derangements of the constitution, how- ever, various substances are found in the urine, which in a diagnostic point of view are highly important, and which we shall shortly notice in succession. To examine the deposits found in urine, this fluid should be poured, in the first instance, and left to stand for a time, in a tall glass jar ; the clear liquid should them be decanted, and the lower turbid portion put into a tall test tube, and the deposit again allowed to form. In this manner, the structural elements are accumulated in the smallest possible compass, so that a large number of them are brought into the field of the microscope at once. The quantity of any salt or deposit in the urine Fig. 100. Spermatozoids as observed in the fluid of Spermatocele. Fig. 101. Cells in fluid removed from an ovarian dropsy. 250 diam. 104 EXAMINATION OF THE PATIENT. can never be ascertained by the microscope. But in the great majority of cases, the appearances observed with that instrument are sufiicient in & <^ \ 'LF (ft? 'v Fig. 102. Fig. 103. themselves to distinguish the nature of the various kinds of sediment met with, and these consequently are all that need be described in this place. Uric Acid.—Uric acid crystals are almost always colored, the tint varying from a light fawn to a deep orange red. The general color is yellow. They present a great variety of forms, the most common being rhomboidal. The lozenge-shaped and square crystals, which are more rarely met with, isolated and in groups, are represented Fig. 102. Not unfrequently they present adhering masses or flat scales with transverse or longitudinal markings, as seen Fig. 103. Occasionally they assume the form of truncated rounded columns, as represented, with other struc- tures, Fig. 108. Urate of Ammonia most commonly assumes a molecular and granular form, occurring in irregularly aggregated amorphous masses (Fig. 105). This may be separated from a similar-looking deposit of phosphate of lime by the action of dilute muriatic acid, which immediately dissolves the last-named salt, but acts slowly on urate of ammonia, setting free the uric acid. Sometimes, ^ however, it occurs in spherical bodies of a bistre brown color, varying in size from the joVntn to the -aoVo*^ °f an mcn m diameter. The latter size rarely occurs. Occasionally they as- sume a stellate form, needle-like or spicular pro- :P..ooco,jgvo.: longations coming off from the spherical body, Fig. 104. I have seen both these forms associated, and the former so curiously aggregated together as to assume the appearance of an organic membrane, for which by some observers it was mistaken, until it was found to dissolve under the action of dilute nitric acid (Fig. M| Triple Phosphate or Ammonio-Phosphate of Magnesia.—These crystals are very com- monly met with in urine, and arc generally well defined, presenting the form of triangular prisms, sometimes truncated, at others having Fig. 105. terminal facets (Fig. 105). If an excess of ammonia exist, or be added Fig. 102. Lozenge-shaped and rhomboidal crystals of uric acid. Fig. 103. Aggregated and flat striated crystals of uric acid. Fig. 104. Urate of ammonia in a granular membranous form, and in rounded masses, with spicula. Fig, 105. Triple phosphate, with various forms of urate of ammonia. 250 diam. USE OF THE MICROSCOPE. 105 artificially, they present a star-like or foliaceous appearance, which, how- ever, is seldom seen at the bedside. Most of the forms of urate of ammonia are represented Figs. 104. and 105 ; in the latter they are associated with the triple phosphate. Oxalate of Lime most commonly appears in the form of octahedra, varying in size, the smaller aggregated together in masses. Once seen, these bodies are readily recognised (Fig. 106). Very rarely they present the form of dumb-bells, or of an oval body, the central trans- parent portion of which pre- sents a dumb-bell shape, while the shadowed dark portion fills up the concavities. Cystine takes the form of flat hexagonal plates, present- ing on their surface marks of similar irregular crystals (Fig. 107). C3 ' /Q-A —• "ft Fig. 106. Fig. 107. Occasionally their centre is opaque, having radiations more or less numerous, passing towards the circumfer- ence. In addition to the various salts found in urine, there may occasionally be found different organic products, such as blood and pus corpuscles, spermatozoids, vegetable fungi, exudation and other casts of the tubes, or epithelial scales from the bladder or mucous passages. Frequently one or more of these are found together, as in the following figure: ft .- •. .» S?\ :'m\ f- Fig. 109. Fig. 108. Very rarely casts of the tubes, principally composed of oily granules, may be seen, or epithelial cells, more or less loaded with similar granules, several of which also float loose in the urine, as in the accompanying figure. Although these casts of the tubes were at one time confounded to- gether, they may now be separated into at least four distinct kinds, Fig. 106. Octahedral and dumb-bell shaped crystals of oxalate of lime. Fig. 107. Flat and rosette-like crystals of cystine. Fig. 108. Bodies observed in the urine of a scarlatina patient, 24 hours after being passed, a, Desquamated fragment of uriniferous tube, b, Exudation casts of uriniferous tubes, c, Amorphous urate of ammonia, d, Columnar crystals of uric acid, e, Blood corpuscles. /, Pus corpuscles, g, Torulse and vegetable fungi, which had been formed since the urine was excreted. Fig. 109. Cast of a uriniferous tube, principally composed of oil granules, with fatty epithelial cell, and free oil granules, in urine of Bright's disease. 250 diam. 106 EXAMINATION OF THE PATIENT. namely,—1st, Fibrinous or exudative ; 2d, Desquamative ; 3d, Fatty; and 4th, Waxy casts. The inferences to be derived from the presence of one or more of these will be specially dwelt on in the section which treats of urinary diseases. Fig. 110. Fig. 111. Spermatozoids are occasionally found in the urine, but must not be considered as of any importance, unless accompanied by the peculiar symp- toms of spermatorrhoea (See Fig. 100). The presence of torulaein consid- erable quantity (Fig. 108, g) is indicative of the existence of sugar, which requires, however, for its confirmation, the application of chemical tests. All the various appearances here noticed are only diagnostic when accompanied by concomitant symptoms. Alone they are not to be depended on; but, in combination with the history and accompanying phenomena, they are capable of affording the greatest assistance in the detection of disease. Fig. 110. Fatty casts, at an early period of formation (/), with granule cells (e), and crystals of triple-phosphate. Fig. 111. Fragments of fatty and waxy casts. One of the latter is represented at the lower part of the figure.—(Christison.) Fig. 112. Tyrozin masses in the urinary sediment of a man with atrophy of the liver.—(Frerichs.) Fig. 113. Leucin in a drop of the same urine, allowed to evaporate.—(Frericlis.) Fig. 114. Pure tyrozin from the same urinary sediment.—(Frerichs). 200 diam. USE OF THE MICROSCOPE. 107 In addition to the elements now and previously described as occa- sionally met with in urine, there should not be overlooked two products, viz., Tyrozin and Leucin. According to Frerichs,* they occur in that fluid in certain diseases of the liver, and especially in acute atrophy of that organ. Hitherto they have not been much studied, having com- monly been mistaken for fatty, starchy, or mineral bodies. But their clinical history, in relation to hepatic and renal disease, having been commenced by so able an investigator as Frerichs, justifies my placing be- fore you the forms which they assume (Figs. 112, 113, 114). Cutaneous Eruptions and Ulcers. An examination of the various products thrown out upon the skin in the different forms of eruption, ulcer, and morbid growth, may in many cases be of high diagnostic value. Of these we shall speak separately. 1. Cutaneous Eruptions.—In the vesicular and pustular diseases, there may be observed below the epidermis all the stages of pus forma- tion, commencing in exudation of the liquor sanguinis, gradual deposi- tion of molecular and granular matter, and formation around them of cell walls. The eruption produced artificially by tartar emetic ointment offers the best opportunity of examining the gradual formation of these bodies under the microscope. Pus taken from all kinds of eruptions and sores presents the same characters, there being no difference between the pus in impetigo and that in variola. When a scab is formed, as in eczema or impetigo, a small portion of it broken down, mixed with water and examined under a microscope, presents an amorphous collection of granules, oil globules, and epithelial scales. The squamous eruptions of the skin are three in number—namely, psoriasis, pityriasis, and ichthyosis. The dry incrustations which form ••^ITr^r j^^P^SISSs^7 on the surface in these diseases, es- ✓ 0 , " _ sentially consist of epidermic scales a-'H^ ■', , -"-VfSg™=. more or less aggregated together. J-' -" 'ft -ii££> They are very loose in pityriasis, : --~^-* and occasionally mingled with de- vs*=c?'s^'-^^sa^^ss1—"^ *bris of vegetable confervae, similar (^2~?; to what grows on the mucous mem- •;-:'-'Oftft:> ''"•-'*-'' brane of the mouth (Figs. 52 and Fig. 115. 53). The scales are more aggre- gated together in psoriasis, and greatly condensed in ichthyosis—occa- sion-ally in the latter disease presenting the hardness and structure of horn. The epidermic tumors of the skin assume the form of corns, callosi- ties, condylomatous warts, and what has been called Verruca achrocor- don. They all consist, in like manner, of epidermic scales more or less condensed together; in the latter growth they surround a canal fur- nished with blood-vessels. Sometimes they assume a regular form, their interior being more or less hard, fibrous, and vascular—in short, a pro- longation of the epidermis (Fig. 115). At other times they soften on * Atlas zur Klinik der Leberkrankheiten. Taf. iii. Fig. 115. Epidermic cells from crust of Psoriasis. 250 diam. 108 EXAMINATION OF THE PATIENT. their summits, and assume the structural peculiarities of the epithelial ulcer afterwards to be described. Fig. 118. 2. Cutaneous Ulcers.- The favus crust is composed of a capsule of epidemic scales, lined by a finely granular mass, from which millions of cryptogamic plants spring up and fructify. The presence of these parasitic vegetations constitutes the pathognomonic character of the disease (see Favus). Other forms of vegetable parasite are occasionally found in connection with the skin, of which that described by Mayer and Grove, in the meatus of the ear, is a good example. The latter, as figured by Beale, is given Fig. 116. The skin is also attacked by certain animal parasites. Of these the pediculi, or lice, are too well known to need description. The Acarus scabiei and the Entozoon folliculorum are described and figured in the section on skin diseases. -In healthy granulating sores, whilst the sur- face is covered with normal pus cor- puscles (Fig. 66), the granulations .themselves present fibre-cells in all stages of development passing into fibres. In scrofulous and unhealthy sores, the pus is more or less broken x(ft down, or resembles tubercle corpus- ■; cles (Fig. 69). The epithelial ulcer is very common on the under lip, commencing in the form of a small induration or wart, Fig. 119. Fig 120. but, rapidly softening in the centre, it assumes a cup-shaped depression, with indurated margins, which extend Fig. 116. Thalli of the fungus found in the ear by Mr. Grove (Beale). See also Trans, of the Microscopical Society, vol. v. p. 161, and plate vii Fig. 117. The fungus {Achorion Schonleini) from'a favus crust." Fig. 118. The same, magnified 500 diameters linear. Fig. 119. Epithelial cells, from the surface of an ulcer of the lip Fig. 120. The same, after the addition of acetic acid. " 250 diam v-ftdSSili mmmm p_.il/tt USE OF THE MICROSCOPE. 10y in a circular form more or less over the cheek and chin. An examina- tion of the softened matter sometimes exhibits epithelial cells, in various stages of development, as in Fig. 119. At other times the cells are enlarged, flattened out, and more or less loaded with fat molecules and granules, or compressed concentrically round a centre, forming what have been called nest cells. These growths, though generally denominated cancer, are at once distinguished by a microscopic examination. The so-called chimney-sweep's cancer of the scrotum is essentially a similar formation (see Epithelioma). The cancerous ulcer of the skin is often difficult to distinguish microscopically from the epithelial ulcer, because the external layer, like it, is often composed of softened epidermis. When, however, a drop of cancerous juice can be squeezed from the surface, it is found to contain groups of cancer cells, which, from their general appearance, may for the most part be easily distinguished. Considerable experience, however in Fig 123. the knowledge, and skill in the demonstration, of cancerous and cancroid growths, are necessary in order to pronounce confidently on this point, and to this end an acquaintance with the whole subject of the histology of morbid growths is essential.* * See the Author's Treatise on Cancerous and Cancroid Growths. Edin. 1849. Fig. 121. Epidermic cells from the edge of a softened epithelioma. Fig. 122. Other cells from the centre of the softened portion. Fig. 123. Appearance of section of cancerous ulcer of the skin.—a, Epidermic scales and fusiform corpuscles on the external surface, b, Group of epidermic scales. c, Fibrous tissue of the dermis, d, Cancer-cells iafikrated into the fibrous tissue, and filling up the loculi of the dermis. 250 diam. 110 EXAMINATION OF THE PATIENT. USE OF CHEMICAL TESTS. The chemical examination of urine, blood, milk, and other animal fluids, as well as the detection of poison in vomited matters, or other organic mixtures and tissues, constitutes an extensive field of inquiry,— for a description of which I must refer to works on chemistry and medical jurisprudence. At the bed-side much of this kind of investi- gation is now superseded by the use of the microscope, which at a glance enables us to detect the poverty and adulterations of milk, the spissitude and altered conditions of blood, the nature of various salts and precipi- tates in urine, etc. The action of chemical reagents on the corpuscles, made visible by this instrument has been already alluded to. Chemical tests are most valuable at the bed-side, to determine the presence of albumen, bile, sugar, or chlorides in the urine, to which points alone I shall in this place direct your attention. All quantitative analyses of urine should only be taken by skilful analytical chemists. Before proceeding to test the urine for particular substances, notice should be taken of its general properties; such as its average daily quantity, its color, odor, density, and reaction. The naked-eye cha- racters of the cloud or precipitate which appears in almost every kind of urine, when allowed to remain at rest for some time after emission, should also be observed, and its morphological constituents determined by means of the microscope. The observation of one or more such properties may lead at once to the establishment of a correct diagnosis, and will certainly direct the path we should take in the subsequent chemical investigation of the fluid. The Specfc Gravity of the Urine is at once obtained by means of a urinometer, and should always be noted at the commencement of the examination of this fluid, as it furnishes important indications for further proceedings. Thus the specific gravity is generally diminished in chronic cases of Bright's disease, and increased in cases of Diabetes. To detect Albumen in the Urine.—Boil a portion of urine in a test- tube over the flame of a spirit-lamp, and observe the result. If the urine, which has in the preliminary examination proved to be acid, become hazy or coagulate, the presence of albumen is certain ; but if it be neutral or alkaline in its reaction, the cloudiness may be occasioned by the deposition of earthy phosphates. One drop of nitric acid should there- fore, in the latter instance, be added, which will immediately clear up the opacity of the fluid if due to phosphates, but serve to increase its turbidity if depending solely on coagulated albumen. To detect Bile in the Urine.—The test for bile-pigment is nitric acid, which changes the fluid containing it in any quantity, first into a grass green, and then, if the test be added in excess, into a ruby-red or reddish brown tint. If the urine be very much loaded with bile, as sometimes happens in cases of jaundice, so that it resembles porter in appearance, USE OF CHEMICAL TESTS. Ill it is better to dilute it with water before adding the acid. If the te\st be applied to the urine, placed in a clean white plate, so as to form a thin layer over the surface, the play of colors may often be distinctly seen assuming green, violet, pink, and yellow hues. The same succession of tints may be induced by nitric acid acting upon urine containing an excess of indican (Schunck), in consequence of this substance being resolved into blue and red indigo, which are subsequently destroyed by the continued action of the acid. There is, however, little chance of fallacy arising from this source, as a marked excess of indican has hitherto only been observed in two cases (Carter), and never in connec- tion with urine presenting a bilious appearance. To detect Bile Acids in the Urine.—Pettenkofer's test for the biliary acids is applied in the following manner. A few drops of simple syrup are mixed with a small quantity of urine contained in a test-tube, or still bettar, in. a porcelain capsule; concentrated sulphuric acid is then gradually added in considerable quantity. If choleic acid be present, the mixture will exhibit a most intense and beautiful purple or violet color. The vessel employed should be placed in cold water before the acid is added, in order to prevent the sugar being decomposed into certain brown compounds, which would tend to obscure the development of the reaction which has been described. True bile is seldom found in urine, even when large quantities of the coloring matters exist. To detect Leucin and Tyrozin in the Urine.—They may be deposited spontaneously, if not the urine should be evaporated on a sand or water bath to a syrupy consistence and set aside for 24 hours to allow of depo- sition. The characteristic forms if present are detected with the micro- scope (see Figs. 112 to 114). To detect Sugar in the Urine.—The three best tests for sugar in urine are those known as Moore's test, Trommer's test, and the Fermentation test. Moore's test consists in boiling urine for five minutes, in a tube, with half its bulk of liquor potassae. If sugar be present the liquid assumes a brownish bistre color. Trommer's test consists in adding a few drops of a solution of sulphate of copper, so as to give the urine a pale blue color ; liquor potassae is then added until the hydrated oxide ir of copper thrown down is again dissolved, which will happen if the urine be saccharine. The clear deep blue solution which is formed must now be boiled; when, if sugar be present in very minute quantity, it will be indicated by the mixture assuming a yellowish-red opalescent tint; but if in large amount, by its becoming perfectly opaque from the formation and precipitation of the yellow sub-oxide of copper. If the urine con- tain no sugar, a dark-green precipitate only is formed on ebullition. Fermentation test.—A few drops of yeast should be added to urine and a test-tube completely filled with the mixture inverted and allowed to remain in a saucer, containing a little more of the urine. The whole should then be put in a warm place, of about 70 or 80 degrees, for 24 hours. Fermentation ensues, and carbonic acid is formed, which collects at the top of the tube, displacing the fluid. The test is now but seldom 112 EXAMINATION OF THE PATIENT. employed, being tedious of application, and not giving such accurate results as was at one time supposed. Barreswil's solution is very useful when many observations are to be made for the detection of grape sugar in the urine. Take of bitartrate of potash and crystallized carbonate of soda, of each 150 parts, of caustic potash 80 parts, of sulphate of copper 50 parts, and of wrater 1000 parts; dissolve the carbonate of soda and potash in part of the water boiling, then add the sulphate of copper powdered. When all the bitartrate is dissolved, add the rest of the water, and filter. A few drops of this solution added to a little urine in the test-tube will, under the action of heat, throw down a dirty green or yellow precipitate of sub-oxide of copper, if sugar be present. To detect Chlorides in the Urine.—Add to urine in a test-tube about a sixth part of its bulk of strong nitric acid, and then a few drops of a solution of nitrate of silver. If any soluble chloride be present, the chlorine1 will be thrown down in combination with the silver, as a white precipitate; but if none exist the fluid will remain clear. From the degree of turbidity or haziness occasioned by the addition of the silver solution, a rough estimate may be made of the amount of chlorides con- tained in the urine. A small case I have caused to be arranged will be found useful for examining urine by the practitioner, as it is readily carried in the pocket. Fig. 124. It contains a spirit-lamp, test-tube, two glass-stoppered bottles, test- paper, matches, and a file for striking fire. (See Fig. 124.) In concluding this subject, allow me to impress upon you the great importance of making yourselves acquainted with all the modes of ex- amination I have brought before you, rather than one or more of them. It too frequently happens that exclusive attention to a particular method of exploration has rendered some medical men good observers of syinp- Fig. 124. A pocket case, containing a spirit-lamp, two stoppered bottles, test-tube, test-paper, with matches and file for obtaining alight. Half the real size. Sold by Kemp, Infirmary Street. EXAMINATION OF THE PATIENT. 113 toms, whilst they are unacquainted with physical diagnosis ; and again, among those who have cultivated the latter, there are some who can percuss and use the stethoscope with skill, who are ignorant of the use of the microscope. Now, you should regard all instruments only as means to an end. In themselves they are nothing, and can no more confer the power of observing, reflecting, or of advancing knowledge, than a cutting instrument can give the judgment and skill necessary for performing a great operation. We should learn to distinguish between the mechanical means necessary for arriving at truths, and those powers of observation and mental processes which enable us to recognise, compare, and arrange, the truths themselves. In short, rather endeavor to observe carefully and reason correctly on the facts presented to you, than waste your time in altering the fashion and improving the physical properties of the means by which facts are ascertained. At the same time these means are absolutely necessary in order to arrive at the facts on which all correct reasoning is based; and perhaps no kind of knowledge has been so much advanced in modern times by the introduction of instruments, and by physical means of investigation, as that of medicine. These enable the practitioner to extend the limits to which otherwise his senses would be confined. Chest-measurers, pleximeters, stethoscopes, microscopes, specu- la, probes, etc. etc., are all useful, and in particular cases indispensable. I do not say employ one to the exclusion of the other, but be equally dexterous in the use of each. Do not endeavor to gain a reputation as a microscopist, as a stethoscopist, or as a chemist; but by the appropriate application of every instrument and means of research, seek to arrive at the most exact diagnosis and knowledge of disease, so as to earn for your- selves the title of enlightened medical practitioners. Above all, do not be led away by the notion that any kind of reasoning or theory will enable you to dispense with the careful observation of facts. What is called tact and skill is not a peculiar intuition, or a superior power of intelli- gence possessed by certain persons, but is always the result of constant and laborious examination of symptoms and signs in the living, combined with careful research into the nature of morbid changes discovered in the dead. 8 SECTION II. PRINCIPLES OP MEDICINE. Every animated being has a limited period of existence, during which it is constantly undergoing a change. So long, however, as this change takes place uniformly in the different parts of which it is composed, its physiological or healthy condition is preserved. But immediately the action of one organ becomes excessive or weak in proportion to the others, disease, or a pathological state, is occasioned. This state may be induced by direct mechanical violence, but may also occur from the continued or irregular influence of several physical agents upon the body, such as temperature, moisture or dryness, certain qualities of the atmosphere, kinds of food, etc. etc. These are always acting upon the vital powers of the individual'as a whole, as well as incessantly stimulating the various organs to perform their functions. Life, then, may be defined in the words of Beclard—" organization in action." Health is the regular or normal, and disease the disturbed or abnormal condition of that action. While such may be assumed to be our notion of disease in the abstract, what constitutes disease in particular has been much disputed. From the time of Hippocrates to that of Cullen and his followers, the external manifestation or symptoms constituted the only means of recog- nizing diseased action, and gradually came to be regarded as the disease itself. Then these symptoms were arranged into groups, divided, sub- divided, and named, according to the predominance of one or more of them, or the mode in which they presented themselves. These artificial arrangements are the nosologies of former writers. All philosophical physicians, however, have recognised that the true end of medical inquiry is, if possible, to determine rather the altered condition of the organs which produces the disordered function, than to be contented with the study of the effects it occasions. But the difficulty of this inquiry has been so great, and a knowledge of the means of prosecuting it so limited, that it is only within the last thirty years that medicine has been enabled to build up for herself anything like a solid scientific foundation. What has hitherto been accomplished in this way has been brought about by the conjoined cultivation of morbid anatomy, pathology, and clinical observation, greatly assisted, however, by the advance of numerous collateral branches of science, and especially in recent times by chemical and histological investigation. The result has been a complete over- throw of nosological systems. We now attempt to trace all maladies to their organic cause, and just in proportion as this has been successfully accomplished, has medicine become less empirical and more exact. The MOLECULAR AND CELL THEORIES OF ORGANIZATION. 115 organic changes, however, which produce or accompany many diseases have not yet been discovered, and consequently a classification of all maladies on this basis cannot be strictly carried out. The organic cause of epilepsy, hydrophobia, and of many fevers, for example, is as yet un- known. In the present state of medicine, therefore, when the morbid change in an organ is unequivocally the origin of the symptoms, we employ the name of the lesion to designate the disease; but when there is disturbance of function, without any obvious lesion of a part, we still make use of the principal derangement to characterize the malady. Thus as regards the stomach we say a cancer or an ulcer of that viscus, and thereby express all the phenomena occasioned. But if we are un- able to detect such cancer or ulcer, we denominate the affection after its leading symptom, dyspepsia, or difficulty of digestion. In endeavoring to carry out this distinction, however, modern physi- cians have fallen into a great error, inasmuch as tlfty have continued to employ the nomenclature of our forefathers, and use words simply ex- pressive of the presence of symptoms to indicate the altered condition of organs which are the cause of those symptoms. Formerly the term inflammation meant the existence of pain, heat, redness, and swelling; it now represents to us certain changes in the nervous, vascular, and paren- chymatous tissues of a part. Formerly, apoplexy meant sudden uncon- sciousness originating in the brain; now it is frequently used to express haemorrhage into an organ, and hence the term apoplexy of the lung and of the spinal cord. The two ideas are essentially distinct, and bear no reference to each other, because ths same word may be, and often is, employed under circumstances where its original meaning is altogether inapplicable. Hence it is incumbent on every one who applies to organic changes terms which have been long employed in medicine, to define exactly what he means by them. In this way old indefinite expressions, though still retained, will have a more precise meaning attached to them. If, for instance, it be asserted that bleeding cut short an in- flammation, let it be explained what is cut short—whether the symp- toms, the physical signs, a congestion of the vessels, or an exudation of the liquor sanguinis. But notwithstanding the confusion in our nosological systems, and the frequent change of ideas with legard to the nature of morbid actions, which have necessarily resulted from the rapid advance of medicine in late years, it still follows that disease is only an alteration in the healthy function of organs. Hence all scientific classification of maladies must be founded on physiology, which teaches us the laws that regulate those functions. A condensed account of our existing knowledge of physiolo- gical pathology is therefore a necessary preliminary to the clinical study of disease. MOLECULAR AND CELL THEORIES OF ORGANIZATION. It has been a favorite speculation with philosophers in all ages that the infinite variety of matter we see around us is merely the result of a definite combination of atoms. The hypothetical doctrines of Democritus, 116 PRINCIPLES OF MEDICINE. Anaxagoras, and Empedocles appear, after many centuries of discussion, to have converged into a fixed law about fifty years ago, which was formularized by Dalton under the denomination of the Atomic Theory. This theory has unquestionably given a great impulse to chemical science, but has done little for the science of organization. It has facilitated the calculation, and thrown light on the proportional combinations of chem- ical elements, but has taught us nothing whatever as to the develop- ment and growth of plants and animals. Gradual improvement in optical instruments, however, has now enabled us to resolve the ultimate elements of living bodies into minute particles, and convinced us that it is upon our knowledge of their physical and vital properties that our acquaintance with physiological and pathological processes must essentially depend. The theory of Schleiden and Schwann was that all the tissues are derived from minute bodies called cells, and that the cause of nutrition and growth resides in these, and not in the organism as a whole. This doc- trine has led during the last twenty-five years to the exploration of the tissues with the aid of high magnifying powers, and to the discovery of facts and theories which, during that period, have greatly advanced our knowledge, and tended to revolutionize the practice of medicine. But as this knowledge progressed, it became evident that even the cell doctrine did not embrace all the facts of organization, and that we required a still wider generalization. Hence it appears to me evident that with a view to making further progress, and stimulating to fresh investigation, we must substitute for the hypothetical atoms of the chemist the visible molecules of the histologist, and demonstrate how all research and dis- covery in recent times tend to support a molecular rather than a cell theory of organization. It will be my object, therefore, as the essential foundation for correct principles in medicine, to develop what I consider to be the true law of organic formation—to blend the well-known doc- trine of Schleiden and Schwann into a theory of wider application—to show how the known facts in physiology and pathology give it the most unequivocal support—and, lastly, indicate the manner in which it must constitute the basis of a sound therapeutics. Passing over the views of the older observers, including those of Wolff, Von Baer, Raspail, and others, in which there is much that iuvites atten- tion, the chief theories advanced on this subject may be limited to four. 1. The Theory of Schleiden and Schwann (1839).—In a cytoblas- tema or amorphous substance, found either contained within cells already existing, or else between them in the form of intercellular substance, round corpuscles make their appearance, which are at first structureless or minutely granular. These enlarge and constitute the nuclei, around which a cell wall is formed by molecular deposition, and gradually ex- pands by the progressive reception of new molecules between the existing ones. The interspace between the cell membrane and the cell nucleus is at the same time filled with fluid, and thus a nucleated cell is produced. Cells so formed may remain isolated, or, by subsequent development and coalescence of their walls in different ways, produce all the various tex- tures.* Thus all tissues are derived from cells, and " the cause of nutri- * Schwann & Schleiden's Researches, translated by the Sydenham Society, p. 172, et seq. MOLECULAR AND CELL THEORIES OF ORGANIZATION. 117 tion and growth resides, not in the organism as a whole, but in the sep- arate elementary parts—the cells."* 2. The Theory of Goodsir (1845).—It is not so much the cells as the nuclei of the textures which are the potential elementary parts of the organism, and which therefore may be called centres ofnutrtiion or centres of germination. " As the entire organism is formed at first, not by simultaneous formation of its parts, but by the successive development of these from one centre " (the germinal spot of the ovum), " so the various parts arise each from its own centre, this being the original source of all the centres from which the part is ultimately supplied. From this it follows, not only that the entire organism, as has been stated by the authors of the cellular theory, consists of simple or developed cells, each having a peculiar independent vitality, but there is in addition a divi- sion of the whole into departments, each containing a certain number of simple or developed cells, all of which hold certain relations to one cen- tral or capital cell, around which they are grouped. It would appear from this central cell all the other cells of its department derive then- origin. It is the mother of all those within its own territory." f 3. The Theory of Huxley (1853).—A homogeneous plasma first exists, in which spaces (vacuoles) are formed, and these contain the cell wall, contents, and nucleus. The walls of these spaces are called peri- plast, the nucleus endoplast. This last he considers comparatively an unimportant element. " The periplast, on the other hand, which has hitherto passed under the names of cell wall, contents, and intercellular substance, is the subject of all the most important metamorphic processes, whether morphological or chemical, in the animal and in the plant. By its differentiation every variety of tissue is produced ; and this differen- tiation is the result not of any metabolic action of the endoplast, which has frequently disappeared before the metamorphosis begins, but of in- timate molecular changes in its substance, which take place under the guidance of the ' vis essentialis,' or, to use a strictly positive phrase, occur in a definite order, we know not why." % Whilst each of these theories has numerous facts in its support, no one of them is capable of embracing all the facts of organization. Thus there are several tissues which have never been known to contain, or to originate from cells, such as the sarcolemma, vitelline membrane, ante- rior and posterior layers of the cornea, and capsule of the crystalline lens. The blood corpuscles of mammals are not cells, but nuclei. The striated muscular fibre has been shown by the researches of Savory and Lockhart Clarke to be formed from the molecular mass outside the em- bryonic cells, while the mineral matter of bone is first deposited in the intercellular substance, outside and often at a distance from the cartilage cells. These facts are opposed to an exclusive cell theory, as they are also to a nuclear or germinal centre theory. It is true the originator of this last doctrine was obliged by them to extend the influence of his centre over a certain distance or territory external to it, whereby he hoped % * Schwann and Schleiden's Researches, translated by the Sydenham Society, p. 192. ■f- Goodsir's Anatomical and Pathological Observations, pp. 1 and 2. \ Brit, and For. Med.-Chir. Review, vol. xii. p. 306. 118 PRINCIPLES OF MEDICINE. to embrace the actions which are carried on in the intercellular sub- stance. But, as pointed out by the supporter of the third theory, the centre often disappears while development in the matter outside it is active. A study of the development of the skeleton proves that mineral matter is first deposited outside cells and their nuclei, and proceeds not from, but towards them; while the earthy matter often assumes forms that no known combination of cells can be supposed to produce. On the other hand, there can be no doubt that in many cases development does proceed from the centre, by proliferation both of the nucleus and of the cell; so that the difficulties imposed upon us by each of these theories simply depend upon their exclusive character. 4. The Molecular Theory of the Author.—It was at the meeting of the British Association in Edinburgh (1850) that I pointed out to the Physiological sub-section the defects of the cell theory, as explanatory of the formation of various textures. In 1852 I read another paper on this subject to the Physiological Society of Edinburgh.* But it was at the Glasgow meeting of the British Association in 1855 I brought for- ward the molecular theory of organization,! which may shortly be stated as follows:—The ultimate parts of the organization are not cells nor nuclei, but the minute molecules from which these are formed. They possess independent physical and vital properties, which enable them to unite and arrange themselves so as to produce higher forms. Among these are nuclei, cells, fibres, and membranes, all of which may be pro- duced directly from molecules. The development and growth of organic tissues is owing to the successive formation of histogenetic and histolytic molecules. The breaking down of one substance is often the necessary step to the formation of another; so that the hystoiytic or disintegrative molecules of one period become the histogenetic or formative molecules of another.^ This theory appears to me to comprehend all known facts; to unite the views of Schwann, Goodsir, and Huxley ; and explain the otherwise irreconcilable ideas concerning development sometimes proceeding from the nucleus, at others from the cell, and at others from the intercellular substance. Two leading ideas have governed histologists in their attempts to discover the law of development; the one, that there is an evolution of matter from within; the other, that there is a superposition of matter from without. Facts indicate that, as regards cells and nuclei, both notions are correct; nature, more especially during embryonic life, adopting the first method, and during adult life, the second. But the differences between these notions are more apparent than real, because the molecular theory of organization reconciles the two. It inculcates that it is not a cell or a nucleus only which acts as a centre, but that every molecule is a centre, and is endowed with physical or vital proper- ties which enable it sometimes to act in the one way, sometimes in the other—here within, and there outside cells. * Edinburgh Monthly Journal, May 1852, p. 476. f Report of the British Association for the Advancement of Science, 1855, p. 119. % Proceedings of the Royal Society of Edinburgh, April 1st, 1861, and my Lec- tures on Molecular Physiology, etc., in the Lancet, 1863. MOLECULAR AND CELL THEORIES OF ORGANIZATION. 119 The accompanying figures will serve to illustrate the agency of mole- cules in the production of vibriones under circumstances, where by no possibility can they be attributed to the existence of pre-existing cells. Fig. 125. Fig. 126. Fig. 127. Fig. 123. Fig. 129. If we take a general view of the structural relations of the tissues, we observe that the molecular, cellular, fibrous, and tubular elements are more or less mingled together, but that some tissues abound in one, and others in another. Thus the molecular element abounds in the nutritive fluids, in voluntary muscle, and in the grey substance of the cerebral con- volutions ; the cellular element abounds in adipose, in glandular, and in epithelial tissues; the fibrous element in areolar texture, ligament, ten- don, and muscular tissues; and the tubular element in brain, spinal cord, bone, tooth, and throughou': the body in the form of minute ducts, nerves, and blood-vessels. They all, as we have seen, serve general pur- poses in the economy. The molecular may be regarded as nutritive, or as Dr. Beale has called it, germinal matter. The cells serve to elaborate this matter for secretion, excretion, and certain kinds of growth. The fibres connect parts together, and in the molecular form of muscular fibre present the highest degree of contractility. The tubes conduct nutritive fluids, and the nerve-tubes that influence, which is capable of exciting action in brain, voluntary muscle, glands, and vessels, by bring- ing each texture in connection with, or under the control of, thought. We perceive further that those actions which are peculiarly vital— such as growth in certain directions, the power of contractility, and the existence of sensibility—are not, as some have supposed, the peculiar attribute of any one peculiar element of the textures, such as of cells or nuclei. I regard one and all as possessing powers which are necessary for the well-being of the economy, and each as reacting for the common welfare on one another. Thus growth may be molecular, cellular, fibrous, or tubular. Contractility and spontaneous movements may be present in each of these elementary forms ; and sensibility unquestionably is shared by nervous matter, at least in its molecular, cell, and tubular forms. As to development, the molecular is the basis of all the tissues. The first step in the process of organic formation is the production of an organic fluid; the second, the precipitation in it of organic molecules, from which, according to the molecular law of growth, all other textures are derived, either directly or indirectly. Whea we investigate the functions of plants and animals—for ex- ample, generation, nutrition, secretion, motion, and sensation—we find Fig. 125. Molecular structure of the scum on its first appearance on a clear animal infusion. Fig. 126. Molecular structure of the same six hours afterwards. The molecules are separated and the long ones (so-called Vibriones) in active movement. Fig. 127. The same on the second day. Fig. 128. The same separated. The molecules uniting in rows which are moving rapidly across the field of the micro; cope. Fig. 129. Filaments (so-called Spirilla) formed by aggregation of the molecules, in the same scum on the third and fourth days, all in rapid motion. 800 diam. linear. 120 PRINCIPLES OF MEDICINE. them all necessarily dependent on the permanent existence and constant formation of molecules. Thus generation, both in plants and animals, is accomplished by the union of certain molecular particles called the male and female elements of reproduction. Among the Protophyta, the conjugation of two cells enables their contents, or the endochrome, to mix together. This endochrome is a mass of colored molecules, and the union of two such masses constitutes the essential part of the genera- tive act. In the Cryptogamia, a vibratile antheroid particle enters a germ cell, and finds this last filled with a mass of molecules which, on receiving the stimulus it imparts, assumes the power of growth. It is the same among the Phanerogamia, when the germ cell is impregnated by the pollen tube. In all these cases it is necessary to remember that the protoplasm is a mass of molecules; that a spore is another mass of molecules; that sporules are molecules ; the antherozoids are only mole- cules with vibratile appendages; and that the so-called germinal matter of the ovule is also nothing but a mass of molecules. Cell forms are subsequent processes, and once produced may multiply endogenously, by gemmation or cleavage. All that is here contended for is, that the primary form is molecular, and that the force-producing action in it is a molecular force. In animals, as in vegetables, every primary act of generation is brought about by the agency of molecules. The Protozoa entirely con- sist of mere molecular gelatiniform masses, in which no cell-wall or central cell exists. And yet such masses have the power of independ- ent motion, and of multiplying by gemmation. Considerable discussion has occurred as to whether, among Infusorians, there is a union of sexes or a conjugation similar to what occurs among the Protophyta ; but in either case it is by molecular fusion that the end is accomplished. In the higher classes of animals there are male elements, consisting of mole- cules, generally with, but sometimes destitute of, vibratile filaments; and female elements, composed of the yelk within the ovum, containing a germinal vesicle or included cell. Both spermatozoid and germinal vesicle are dissolved in the molecules of the yelk, which then, either wholly or in part, by successive divisions and transformations, constitute a germinal mass out of which the embryo is formed. Here, as in plants, it is necessary to remember that the spermatozoids, the yelk, and the germinal mass, are all composed of molecules; and that these, combining together, form the nuclei, cells, fibres, and membranes, which build up the tissues and organs of the organism. It is not from either the male or the female element that the embryo is formed. The supporters of an exclusive cell doctrine have endeavored to show that there is always a direct descent either from the wall of the ovum or from the germinal vesicle as its nucleus. Thus some consider that the vitelline membrane sends in partitions to divide the yelk mechanically. Others have formed the idea that the germinal vesicle bursts, and that its included granules constitute the germs of those cells which subsequently form in the germ- inal mass. ^ Others, again, suppose that on impregnation the germinal vesicle divides first, and that the molecules of the yelk are attracted round the two centres so formed. But numerous observations have satisfied me that both spermatozoid and germinal vesicles are simply dis- MOLECULAR AND CELL THEORIES OF ORGANIZATION. 121 solved among the molecules of the yelk, from the substance of which stimulated and modified by the mixture so occasioned, the embryo is formed—a view which has further the merit of explaining what is known of the qualities of both parents observable in the offspring. The truth appears to be, that in an analogous manner to that in which the pigment molecules of the skin are stimulated by the access of light to enter into certain vital combinations with one another, so are the mole- cules of the yelk stimulated by the access of the spermatozoid to produce those other vital combinations that result in a new being. The essential action is not so much connected, as has hitherto been supposed, with the cell-wall or nucleus as with the molecular element of the ovum. With regard to nutrition, food and all assimilable material must be reduced, in the first instance, to the molecular form ; while the fluid from which the blood is prepared—namely, chyle—is essentially molecular. Most of the secretions originate in the effusion of a fluid into the gland follicle, which becomes molecular, and gives rise to cell formation. In muscle, the power of contractility is inherently associated with the ulti- mate molecules of which the fasciculus is composed. And lastly, the grey matter of the sensory ganglia and of the brain, which furnish the conditions necessary for the exercise of sensation and of even intellect itself, is associated with layers of molecules which are unquestionably active in producing the various modifications of nervous force. These molecules are constant and permanent as an integral part of these tissues, as much as cells or fibres are essential parts of others; and their presence is not transitory, but essential to the functions of tho organs to which they belong. All morbid growths may easily be shown to originate either in a molecular blastema, or in pre-existing cells. The coagulated exudation infiltrated into the lung, or on the serous membranes, and from which pus and fibre cells originate, are excellent examples of the former; while the hypertrophy of glands, and formation of certain carcerous and cancroid growths, are good illustrations of the latter. In morbid alterations of texture, also, we shall have abundant opportunities of pointing out that the molecular law of development prevails, and that histogenetic and histolytic groups constitute the numerous alterations of texture con- stantly brought under the observation of the pathologist. Kg. 130. Fig. 131. Fig. 132. Fig. 138. All these facts point to the conclusion that vital action, so far from being exclusively seated in the cells, is also intimately associated with the elementary molecules of the organism. This molecular theory of organization is opposed to the views of Fig. 130. Nuclei imbedded in a molecular blastema. Fig. 131. Young fibre cells formed by aggregation of molecules around the nuclei, Fig. 130. Fig. 132. Cancer cells, one with a double nucleus. Fig. 133. Histolytic, or so-called granule cells, break- ing down from fatty degeneration. 250 diam. linear. 122 PRINCIPLES OF MEDICINE. those who support an exclusive origin for the tissues in cells alone. The fallacy of such a cell theory will, however, be manifest by considering for a moment what it imposes upon us. Not the fact, which has been long recognized, that cell may be formed within cell, or that proliferation of cells constitutes an important and a common method of cell multipli- cation ; but that in no other possible way can a cell or a living particle be produced. It asserts that all embryonic textures in the ovum, all adult tissues during life, and every kind of morbid formation, are to be traced to the cell, and can originate in it alone. In short, parodying the celebrated saying of Harvey, " omne animal ex ovof it has been attempted by Virchow to establish the law of " omnis cellula e cellula,'1'1 and to maintain that " the cell is really the ultimate morphological element in which there is any manifestation of life, and that we must not transfer the seat of any real action to any point beyond the cell." * Now, I have pointed out to you that such a doctrine is inconsistent with numerous facts, and we shall see that histologists (including Virchow himself) have been so unsuccessful in tracing all tissues back to cells, that they have universally recognised that cells must originate in the first instance, from a formless or molecular fluid or material, called by Schwann a blastema. Besides, no attempt has been made (even by Virchow) to show that muscle, nervous matter, the vascular system, and the blood, only originate in cells. He himself admits,! that this cannot be established. Several tissues are absolutely structureless, such as the sarcolemma, the neurilemma of the nerve tube, the vitelline membrane, the anterior and posterior layers of the cornea, and the capsule of the crystalline lens. They are apparently the result of simple coagulation and the subsequent union of minute molecules, such as occurs in the haptogen membrane. The blood of mammals is for the most part not cellular but nuclear, and we shall subsequently see that the nuclei in the adult are more probably the result of molecular than of cell formation. The development of bone and the various forms mineral matter assumes in the integumentary skeletons of many animals, such as the Holothuria, Sinaptae, etc., are wholly opposed to this cell theory, the mineral matter being deposited outside the cells, and often assuming the form of spicules, hooks, anchors, etc., which can have no possible reference to cell growth. Then, so far from it being correct, " that we must not transfer the seat of real action to any point beyond the cell," which is another fundamental part of this cell theory, you will find that Virchow admits % that the contractile action of a muscle is seated in its ultimate granules ; and he adopts $ Du Bois-Reymond's theory of electrical action in nerve as being dependent on " a change in the position which Me individual molecules assume to one another." If, therefore, it cannot be shown by the chief supporter of this theory that many important tissues are formed directly from cells, and if it be admitted that the vital actions of these same tissues are inherent in their ultimate molecules—elements in no way connected with and quite distinct from cells—what becomes of the formula omnis cellula e celluld, and of the doctrine that " we must not transfer the seat of real action to any point beyond the cell ? " * Cellular Pathology, by Chance, p. 3. \Ibid., p. 50. $/6id, p. 54. %lbid., p. 290. MOLECULAR AND CELL THEORIES OF ORGANIZATION. 123 On the other hand, the molecular theory of organization does not appear to me chargeable with any such defects. It is consistent as a whole, and embraces all known facts. As investigations are multiplied, the more it becomes evident that the ultimate vital elements of the tissues are their molecular, and not their cell, constituents. Indeed, it is now agreed by many upholders of a cell theory, that the potential part of the cell is not the wall nor the nucleus, but the contents. Now these con- tents are for the most part molecular ; and if we must have a doctrine of unities, it is evidently more reasonable to adopt a view of simple unities like molecules, than of composite advanced formations like cells. As a whole, the molecular theory appears to me to possess all the attributes of a true theory, and as such I have no hesitation in recommending it to your adoption, not only as a basis on which the formation of healthy structure may be explained, but as one eminently valuable when applied to morbid formations, and, above all, in assisting us to reach (as we shall subsequently endeavor to show) correct modes of treating disease and a true therapeutics. From what has been said, it will be apparent that it has not been my object, in directing attention to a molecular theory of organization, to in- terfere in any way with the well-observed facts on which physiologists have based what has been called the cell-theory of growth. True, this last will require modification, in so far as unknown processes of growth have been hypothetically ascribed to the direct metamorphosis of cell elements. But a cell once formed may produce other cells by buds, by division, or by proliferation without a new act of generation, in the same manner that many animals and plants do, and this fact comprehends most of the admitted observations having reference to the cell doctrine. The molecular, therefore, is in no way opposed to a true cell-theory of growth, but constitutes a wider generalization and a broader basis for its opera- tions. Neither, does it give any countenance to the doctrines of equivocal or spontaneous generation. It is not a fortuitous concourse of molecules that can give rise to a plant or animal, but only such a molecular mass as is formed from organic substances, and receives the appropriate stimulu3 to act in certain directions.* The molecular theory of organization must ultimately constitute the ba- sis for the arts of horticulture, agriculture, andmedicine. Thus vegetables and animals grow by the juxtaposition of molecules which are introduced into the economy in the fluid form. This fluid holds in solution the particles of which the different textures consist. These are deposited, and so increase of bulk takes place. Any interruption to this process, or any violent disturbance in their statical, chemical, or dynamical arrangements when formed, is the fruitful cause of disease. If this occurs in nervous matter, it causes pain, convulsions, and spasms; if in muscle, paralysis; if in the blood, alterations in growth, secretion, excretion, etc. In cases of faulty nutrition, it is reasonable to conclude that if we could add to, or subtract from, the particular molecular elements which are essential to that process, we could accelerate or retard it; and this is within the reach * For an account of the numerous facts which support this doctrine, see the author's lectures on Molecular Physiology, Pathology, and Therapeutics, in the Lancet for 1863. b' 124 PRINCIPLES OF MEDICINE. of the medical practitioner. For example, cod-liver oil, in scrofulous and phthisical cases operates, not because of any vague specific virtue it has been supposed to possess, but on account of its power of adding to the molecular constitution of the chyle, and thus favoring the building-up function of the blood and tissues. There can be no doubt that iron, lead, opium, strychnine, and other of our remedial agents, must operate on this or that tissue in virtue of the affinities between them and the ultimate molecules of such textures. Again the law of successive mole- cular evolutions and disintegrations, to which I have directed your atten- tion, points out that in the chain of processes each step is dependent on the one that precedes it; and that, inasmuch as regards form, we cannot go farther back than the molecular form, so a knowledge of it and the manner in which it is produced from fluids holding proximate principles in solution, is not only the first step to an acquaintance with organization, but is the one which should best inform us how to repair that organization when so altered as to constitute disease. ON THE GENERAL LAWS OF NUTRITION IN HEALTH AND DISEASE. There have not been wanting some pathologists who have ascribed the origin of all diseases to an altered condition of nutrition and of the blood, whilst others have regarded even this function as subservient to that of innervation. In man, it is true, we find them inextricably united, and it becomes exceedingly difficult at all times to separate with exacti- tude what are the purely nutritive, and what the purely nervous pheno- mena. But a consideration of animated nature at large must satisfy us, that in the vegetable world, as well as in some forms of animal life, nutri- tion may proceed independently of a nervous system. We also feel satisfied that, in theory as well as in fact, the function of nutrition is capable of being separated from that of innervation. Doubtless there is no lesion whatever which does not in the higher class of animals involve both nutritive and nervous changes; but the only method of arriving at a knowledge of their conjoint action, of their mutual influence, or the manner in which sometimes one predominates over or mingles with the other, is by studying in the first instance the laws by which each seems to be governed. Function of Nutrition. The various modes in which nutrition becomes impaired, and the blood diseased, can only be understood by passing in review the different steps of the nutritive process. We have already pointed out how pathology and practical medicine must be based upon anatomy and physiology, anil there is no one subject perhaps which is so well capable of illustrating this proposition as the one we are about to consider. For ages medical men have been in the habit of considering the blood to be the primary source of numerous maladies. It will be our endeavor to show, by an analysis of the process of nutrition, that the changes of the blood and the diseases which accompany them, are for the most part not primary but HEALTHY AND DISEASED NUTRITION. 125 secondary—that is to say, they are dependent on previously existing cir- cumstances, to the removal of which the medical practitioner must look for the means of curing his patient. For the sake of convenience of description and reference, we shall divide the process of nutrition in man into five stages. 1. The introduc- tion into the stomach and intestinal canal of appropriate alimentary mat- ters. 2. The formation from these of a nutritive fluid, the blood, and the changes it undergoes in the lungs. 3. Passage of fluid from the blood to be transformed into the tissues. 4. The disappearance of the transformed tissues and their re-absorption into the blood. 5. The excretion of these effete matters from the body, in various forms and by different channels. These different stages comprehend not only growth, but the processes of assimilation, absorption, secretion, and excretion ; and we believe that it is only by understanding the function in this enlarged sense that we can obtain a correct explanation of those important affections, which may appropriately be called diseases of nutrition. We shall first, however, consider each of these stages separately. 1. The Introduction into the Stomach and Intestinal Canal of Appro- priate Alimentary Matters. Aliment.—All the various kinds of food are resolvable into the four elements—Carbon, Hydrogen, Oxygen, and Nitrogen, combined with certain mineral bases. The chemical constitution of plants and animals is nearly the same; and hence food derived from one kingdom of nature must contain those substances of which the bodies to be nourished in the other kingdom are themselves made up. The quantity required is prin- cipally regulated by the amount of air we breathe, its oxygen uniting with the carbon and hydrogen of the tissues to produce carbonic acid and water, and to evolve the heat of the body. In endeavoring, therefore, to ascertain what are the best kinds of food requisite for meeting the demands of supply, we must pay attention, in the first place, to the chemical principles which enter into the constitution of the living being to be nourished; secondly, to the mode in which these are combined to form tissues and organs; thirdly, to the atmosphere which surrounds it; fourthly, to the amount of waste it undergoes; and fifthly, to the structure of the animal. The results of numerous investigations, carried on with the view of determining these points, are as follows:— 1st, The proximate chemical principles required for the nourishment of man are the albuminous, the fatty, and the mineral principles. The first of these are substances rich in nitrogen—such as fibrin, caseine, and albumen, which occur both in the vegetable and animal worlds. The second are substances devoid of nitrogen, consisting of the animal and vegetable fats, together with starch, sugar, and gum, which by deoxida- tion are readily converted into fat. The third are mineral salts, more especially phosphate of lime and chloride of sodium. It has been proved that every kind of nutritive food must contain ail three principles; and that the absence of any one of these induces starvation and death. Water is also necessary as a diluent. 126 PRINCIPLES OF MEDICINE. 2d, It is not mere nitrogenous or non-nitrogenous kinds of food that will serve for nourishment, as is theoretically supposed by chemists. To form tissue, these chemical constituents must be converted into albumen and oil, so as to produce those elementary molecules of the chyle which constitute the formative substance of the blood cells; while the mineral constituents must be dissolved in the fluid in which these float. All three elements exist in every tissue ; but the fibrous tissues abound in albumen, the glandular organs in fat, and the bones in mineral matter. 3d, The amount of oxygen in the atmosphere greatly influences the quantity of food required. If cold and condensed, more oxygen will unite with the tissues, and more nourishment will be required to meet the demand and prevent waste. If warm and rarefied, the appetite diminishes, and less nutritious food is necessary. 4th, Bodily and mental exercise causes waste of tissue, and active men require more food than those who spend idle lives. An able-bodied laborer, requires at least thirty-five ounces of dry nutritious food; nor can soundness of health be kept up for any length of time under thirty ounces. Sedentary people, it is true, exist upon much less; but they are weak, and generally valetudinarians. Of mixed solid and fluid food there are required daily between six and seven pounds, of which about five pounds on an average consist of water. 5th, Living beings are governed in their selection of food by laws which the chemist cannot elucidate, and which are essentially connected with structure. It may be true, as Mulder pointed out, that the albumen of vegetables and of animals is the same ; but some animals can only live upon one, and some on the other. The chemist has not explained to us why the carnivora reject vegetable and the graminivora refuse animal food, or why the substances which contain least nutritious matter for one class of creatures are the chief means of support for others. Hence, though chemistry may teach us much, the laws of dietetics can only be arrived at by the physiologist. 4 It is unnecessary to dwell at any length upon the fact that of all the causes of disease, irregularity in diet is the most common. Neither need I do more than merely allude to the equally well-known circumstance, that of all the means of cure at our disposal, attention to the quantity and quality of the ingesta is by far the most powerful. The peculiar kind of interference with the aliment, which various diseases require, will be illustrated as we proceed further. Mastication and Insalivation.—The various kinds of solid organic food are, in the first place, broken down by the action of the teeth, jaws, tongue, lips, and cheeks, and thereby prepared for the solvent and chemical actions to which they are subsequently exposed. In the mouth they are intimately mingled with the saliva, a viscous fluid, which is not only necessary for the proper trituration of the food, as well as for articu- lation and deglutition, but which contains an animal principle—ptyaline —that has been proved to possess a peculiar action on starch, converting it into dextrine and glucose. Buccal saliva, however, is a mixed fluid, and, according to Bernard, originates from three sources, each of which communicates special properties to it. Thus the parotid glands secrete a HEALTHY AND DISEASED NUTRITION. 127 clear liquid fluid necessary for mastication; the submaxillary glands secrete a more gelatinous fluid, which is connected with the senee of taste; and the sublingual and palatine glands furnish a viscous, mucous matter, which surrounds the bolus externally, and causes it to slide more easily through the fauces and oesophagus. The peculiar action on starch is not confined to the saliva, although unquestionably strong in that fluid as we find it in the mouth. According to Bidder and Schmidt, about three and a half pounds of it are secreted daily. Digestion in the stomach and intestines.—The food prepared in the mouth is conveyed by the excito-motory act of deglutition into the stomach—a bag in which it is further subjected to gentle trituration and the solvent action of the gastric juice. This fluid, according to Bidder and Schmidt secreted to the extent of about fourteen pints daily, is slightly acid, and contains a peculiar animal principle, pepsine. It has an extraordinary solvent power on the albuminous constituents of the food, as well as gelatin, chondrin, and gluten, which when dissolved in it produce a material called peptone. It has no further effect on fatty substances than that of liquefying them; so that the albuminous and fatty constituents of the food pass into the duodenum in a liquid state, mingled with broken-down portions of animal and vegetable substances, in the form of a pulp, called chyme. In the duodenum this is mingled with the bile and pancreatic juice. The former neutralizes and evidently checks the further action of the gastric juice, and enables the alkaline and albuminous pancreatic fluid to operate on the fatty substances, which, previously liquefied, are- at once minutely divided and emulsionized by it. The pancreatic juice also changes amylaceous matters into sugar within the intestine, and may assist in disintegrating the bile, and rendering it more of an excretory product. The intestinal juice secreted by the Brunerian and other glands of the intestine has been shown by Bidder and Schmidt to be capable of dissolving the albuminous constituents of the food which have escaped the solvent action of the stomach. The same observer tells us that about three and a half pounds of bile are secreted within the twenty-four hours, and about half a pound each of pancreatic juice and of the intestinal juice. The large amount of digestive fluid secreted, amounting in all to twenty-two pounds daily, contain little solid matter, and are evidently designed to dissolve and act chemically on the aliment. While some of them operate more especially on one kind of substance, others do so more particularly on another, at the same time that they are not exclusively directed to one object. Thus the pan- creatic juice may do other things besides emulsionizing fat, and the intestinal juice may perform lower down in the canal what the stomach has failed to accomplish. Then the importance of the peristaltic move- ments of the intestines must not be overlooked, which intimately mix the food with the different secretions, and constantly propel the mass from above odwnwards along the tube. Lastly all the various processes are uecessary to, and assist one another. The saliva, when swallowed, stimu- lates the secretion of gastric juice, as does this in its turn the flow of bile, the pancreatic and the intestinal juices; and hence why indigestion may arise from a permanent excess, diminution, or perversion of any of the actions concerned in the digestive process. 128 PRINCIPLES OF MEDICINE. 2. The Formation from Alimentary Matters of Nutritive Fluid, the Blood, and the Changes it undergoes in the Lungs. Chylification and Sanguification.—The food, prepared and acted upon in the manner described, is gently propelled by the peristaltic contractions of the alimentary canal along its interior, and is at the same time pressed against the numerous villi that project from all parts of the small intestine. These organs, covered with a layer of conical or cylindrical epithelial cells, imbibe the more finely molecular particles of the chyme, which pass through the delicate walls of the cells, and may be seen shortly after digestion collected in them. The fluid of the chyme is for the most part absorbed by the blood-vessels. From the epithelial cells the molecular material passes through the basement membrane of the villi, and finds its way into the chyle ducts, whence it is conveyed to the lymphatic glands. The passage of the molecular matter from the chyme into the epithelial cells is probably owing to endosmose, assisted by the mechani- cal pressure exercised by the muscular walls of the intestine. The mechanism of the transmission of the molecular chyle into the primary chyle duct is unknown. A lymphatic gland consists of pouches or sacs, surrounded by a firm fibrous membrane, which is richly supplied by blood-vessels. The interior of these pouches or sacs contains a molecular fluid, in which numerous nuclei and a few cells may be found in all stages of development. The glands of Peyer I agree with Brucke in considering as the first series of lymphatic glands. These are succeeded by other series in the mesentery All of them are connected with one another by lacteals, which ultimately terminate in the thoracic duct. They serve to subject the molecular chyle as it is first derived from the chyme to the action of these glands. There the onward flow of the fluid is somewhat delayed; an exchange takes place between it and the surrounding blood, and nuclei and cells are formed—more especially, however, nuclei—by molecular aggregation, Hence why, on cutting into these glands shortly after digestion, and examining microscopically the fluid they contain, it may be seen that a molecular fluid (first described by Gulliver) is more or less crowded with naked nuclei which resist the action of acetic acid. On repeating the observation on fluid taken from the thoracic duct, the same thing is noticeable, only several of the nuclei are now flattened, and in everv point, except color, closely resemble the blood corpuscles. It is clear, therefore, that chylification and sanguification are perfected through the action of the lymphatic glands upon the molecular chyle; that in them the blood corpuscles are formed, and conveyed by the thoracic duct into the circulation at appoint not far from the right side of the heart; from thence they are rapidly propelled into the lungs, where, on being exposed to the oxygen of the atmosphere, they assume color, and thereby become the colored corpuscles of the blood (Fig. 57). There are other glands which are supplementary to this function of sanguification, and which in consequence were first called by Hewson lymphatic glands. They are the spleen, thymus, thyroid, and supra-renal bodies. These organs also contain pouches or shut sacs, rich in a mole- HEALTHY AND DISEASED NUTRITION. 129 cular fluid, and multitudes of naked nuclei. Like the lymphatic glands, also, they are very vascular, and are connected with the thoracic duct by numerous minute channels or lymphatics. No difference whatever can be distinguished between the glandular contents of these organs and those of the lymphatic glands; and other facts connected with their morbid states—more especially the production of leucocythemia—serve to convince us that, like them, they are connected with sanguification; hence their modern name of blood glands. The whole system of lym- phatic glands may be said to secrete or form the blood corpuscles, although the nature of the blood, as a whole, being very complex, ean- not be clearly understood until we study the results of the secondary digestion. (See Leucocythemia.) Respiration and Circidation.—The lungs are organs so constructed as to expose a large surface, covered with capillaries, to the action of the atmosphere. In man, the air, by going into and coming out of the lungs, loses its oxygen, and has substituted for it carbonic acid, which is given off in the proportion of 1000 of the latter to 1174 of the former gas. The excess unites with the hydrogen, phosphorus, sulphur, and other elements of the tissues, giving rise to various chemical compounds, and serving, in the act of combination, to produce much of the animal heat of our bodies. The amount of carbonic acid gas given off by the lungs varies according to circumstances. Under ordinary circumstances, the amount would yield eight ounces of solid carbon daily; during hard labor, twelve ounces; and during sleep, four ounces. The most important experiments in recent times, as to the excretion of carbonic acid by the lungs, have been made by Dr. E. Smith of London. In determining the influence of food, he made numerous careful experiments; and of the many conclusions he arrived at on this subject I may quote the following:—1. That the influence of food is evident soon after its introduction into the system, and attains its maxi- mum within about two hours. 2. Pure starch and fat do not increase the quantity of carbonic acid evolved, but on the contrary, the latter somewhat lessens it. 3. The cereals, however, which contain, besides starch, albuminous products, gluten and sugar, increase the excretion of carbonic acid to the extent of two grains per minute. 4. Milk, sugar, tea and coffee do the same. 5. Alcohol, rum, and malt liquors increase it to the extent of one grain per minute; but brandy and gin, especially the latter lessen it. 6. Foods may be classified into non-excitants and excitants as regards the excretion of carbonic acid gas. The non-excitants are—starch, fat, some alcohols, and coffee-berries. The excitants are— sugar, milk, cereals, potatoes, gluten, gelatin, fibrin, albumen, tea, coffee, cocoa, chicory, alcohol, rum, and some wines. These results are remarkable as distinguishing starch and fat as non- excitors of increased carbonic acid in expiration, thus confirming what I have long maintained on histological grounds—viz., that fats and oils serve largely to build up the tissues, and are not, as Liebig endeavored to show, merely respiratory food. They are further remarkable in showing that alcohol and rum increase, while brandy and gin diminish the carbonic acid—effects which, if correct, are wholly inexplicable. The effect of respiration on the blood is to give color to the free 9 130 PRINCIPLES OF MEDICINE. nuclei in mammals, and to the cells in the other vertebrata which join the blood from the chyliferous system. It also produces those differences whieh characterise arterial from venous blood. The only novel point I may allude to is the fact shown by Bernard, that venous blood coming from glands in action, is red like arterial blood, and like it, owes its color to excess of oxygen. A perfect chemical theory of respiration is still a desideratum. The circulation of the blood is kept up by the various motor powers of the heart, arteries, capillaries, veins, and lungs, the nature and amount of-which we cannot here dwell upon at length. The most careful investigations made in modern times by Poissieulle, Valentin, and Ludwig, as to the static force of the heart and arteries, show that it is equal to about four pounds on the square inch. Assum- ing the internal superficies of the left ventricle to be about thirteen inches, this would give fifty-two pounds as the force it exerts. Now, Hales, more than a hundred years ago, calculated it to be fifty-one and a half pounds, which must not only satisfy us of his accuracy as an observer, but convince us that no change has occurred in the force of the pulse, either in man or animals, during that time. The importance of this fact I shall allude to subsequently. The experiments of Marey indicate that there are two forces propelling the fluid—one, direct, dependent on the heart or pump; the other secondary, caused by the recoil of the dis- tended blood-tube. The intensity of the latter force, however, gradually diminishes as the wave of fluid recedes from the source of afflux, while the time of the pulse remains the same. What has most attracted attention in recent times is a more correct explanation of the phenomena formerly called determination of blood. This afflux of the blood to different parts of the system, instead of beiug sent by a vis a tergo, is in truth drawn or attracted there by a vis a froute. This force originates in the chemical and vital changes which go on in the ultimate molecules of the part. Stimulation or irritation of texture is the exciting cause, and the result is a flow of fluid towards theHissues or organs requiring it. Examples are seen in the ascent of sap in plants, in the turgid mamma during lactation, in the gums of the infant when teething, in the integuments surrounding the annual growth of the stag's horn, in the circulation of the acardiac foetus, in the female sexual organs during menstruation, in the portal circulation of the liver, and in the congestion of irritated texture preceding inflammation. In all these cases, there is no heart, pulsatile vessel, or pumping apparatus which can especially force the fluid into the parts referred to, and therefore they must draw or attract it by a force the result of molecular action. 3. The Passage of Fluid from the Blood to be transformed into the Tissues. From the blood so formed and elaborated there are constantly passing off, through the capillaries, matters which are transformed into the tissues and secretions. It is necessary that this should take place to an amount proportionate to the matter supplied to the blood by assimila- tion on the one hand, and that dissipated by waste on the other. If more or less be given off, a morbid condition is occasioned. Thus, an increased HEALTHY AND DISEASED NUTRITION. 131 amount in a part gives rise to hypertrophies, a diminished amount pro- duces atrophy. When we endeavor to ascertain in what way this is accomplished, it is clear it cannot be attributed to any power in the blood or blood- vessels, as these are the same in textures and glands the most diversified. We are therefore obliged to ascribe it to an influence seated in the textures themselves. This in its nature must be attractive and selective: attractive, in so far that matters are drawn from the circulation to be added to the textures; and selective, in so far as particular constituents of the circulating fluid are chosen by one tissue, and different ones by another. This power is not seated in cells only, as has been supposed, but in all the tissues. Muscle which is molecular, gland which is cellular, tendon which is fibrous, and brain which is tubular—all possess it. In cartilage, we see it most powerful in the inter-cellular tissue, which is the first to attract from the blood the fluid loaded with mineral particles. Hence it seems to be as strong relatively in the minutest molecule as in the largest cell. This power of growth, then, of which secretion is a modification, is, like the power of contractility and of sensibility, an ulti- mate fact in physiology. For the conditions regulating it, I cannot do better than refer you to the able writings of Mr. Paget. It often happens that the attractive and selective power in the tissues is deranged, so as to produce increase or diminution in growth or in secretion, general or partial. Not unfrequently the selective power appears to be lost, and the attractive power so much increased, that the liquor sanguinis is drawn out through the vessels, so that its fibrin coagu- lates in a mass outside them. This result, preceded or accompanied by certain changes in the vessels themselves, and more or less stagnation of the current of blood, constitutes the phenomena hitherto described as inflammation. Under these circumstances, other cells and tissues, alto- gether foreign to the healthy condition of the economy, are produced in what is now called the exudation, although the same general laws of growth and transformation preside over the abnormal as over the normal products. In this manner pus and cancer cells may be formed, or fibrous, cartilaginous, osseous, and other tissues causing different kinds of morbid growth. 4. The Disappearance of the Transformed Tissues and their Re-absorption into the Blood. The secondary digestion.—Growth having been effected, it is necessary that the particles of the tissues which have fulfilled their function and are worn out should be removed to give place to new ones. This con- stitutes the so-called secondary digestion; that is, in the same way that a piece of food—say flesh—is broken down, rendered molecular and fluid, and is absorbed into the blood to add bulk to the frame, so is our own living flesh constantly breaking down, rendered molecular and fluid, and absorbed into the blood, to be finally thrown out of the system. Thus the blood receives matter from two sources—the primary and secondary diges- tions ; and is continually giving off matter in two directions—one to build up the tissues and form the secretions, the other to produce the excretions. 132 PRINCIPLES OF MEDICINE. Chemical constitution of healthy blood.—Numerous analyses have been made of this fluid by the most distinguished chemists, and yet no two of them have been alike. This is explained by the fact that the chemical constitution of blood must constantly be undergoing changes, not only in various individuals, but in the same individual, from differ- ences in diet, assimilation, respiration, excretion, exercise, and the numerous circumstances which influence the animal economy. It also varies in the two sexes. From a calculation deduced from numerous analyses, I think you may adopt the following conclusions with safety as to the chemical constitution of the blood in health:—1. That the great bulk of the blood is made up of water, varying from 760 to 800 parts in 1000 parts. 2. That the fibrin is very small in quantity, varying from li to 3 in 1000 parts. 3. That the amount of albumen ranges between 60 to 70 parts. 4. That the amount of corpuscles ranges between 130 to 150 parts. 5. That the extractive matter and fat range from 1 to 4 parts. 6. That the saline matters range from 5 to 10 parts. Function of the blood.—The blood circulating through the body may be regarded as a river flowing by numerous canals through a populous city, which not only supplies the wants of its inhabitants, but conveys from them all the impurities which through various channels find their way into its stream. The chief supplies enter the circulation, as we have previously seen, in the form of water and of blood corpuscles from the primary digestion. These receive oxygen in the lungs, where they be- come colored, are sent all over the body, and in the ultimate capillaries yield up their oxygen, which combines with carbon and other chemical constituents of the tissues to form numerous combinations. After a time they are dissolved in the liquor sanguinis, which fluid they serve to elaborate. The blood also receives and holds in solution the products of the secondary digestion, so that it is a highly elaborated, viscous, and eomplex organic liquid. It is the blastema from which, on the one hand, the living molecules, nuclei, cells, and other elements of the tissues, are attracting new matter to supply the place of what is lost, while on the other, they are imparting to it old matter which has sufficiently served the purposes of the frame. In what manner this important fluid utilizes the various products it receives from both sources is as yet unknown. All that we can determine is that the whole is in incessant motion, rushing rapidly out from the heart through the arteries, divided into minute streams by capillaries in the tissues, returning more slowly by the veins —a circuit through the frame completed in half a minute—subjected to the constant collision of about two billions of semi-solid corpuscles, inces- santly undergoing chemical alterations when exposed to the peculiar action of every organ in the body; and while giving off one or more of its constituent principles in this or that tissue as it passes through it, at the same time taking up those which have been worn out in the service of the economy. Blood, therefore, is the mixture of the histo- genetic and histolytic processes of the body. It is in the circulation they mingle together, and it is there consequently we must look for an ex- planation of numerous morbid conditions which derangements in so nicely balanced an organic fluid may be expected to produce. Morbid conditions, of the blood.—I need not dwell upon the vast HEALTHY AND DISEASED NUTRITION. 133 importance which from the earliest times has been attached to alterations in the blood as the cause of disease. The red, white, yellow, and black bloods of Hippocrates—the acid and alkaline blood of Van Helmont— the error loci among the blood corpuscles of Boerhaave—and the sthenic and asthenic states of the constitution contended for by Brown and Broussais—have each in turn regulated the medical practice of civilized nations. In recent times, most laborious efforts have been made by means of the microscope and of chemical researches to investigate the exact condition of the blood in disease. The changes which occur structurally have been previously noticed (see p. 92); and the discovery of leucocythemia by myself, of the softening and breaking up of blood coagula by Gulliver, of the effect of emboli by Virchow, and other mor- bid conditions of that fluid, will be subsequently referred to. Chemical alterations of the blood in disease.—The most laborious investigations into this subject have been made by the French chemists and pathologists, more especially by Andral and Gavarret, in 1840, and by Becquerel and Rodier, in 1844, whose researches have for the most part been confirmed by subsequent investigators. The results which the latter chemists arrived at are as follows :—1st, Venesection greatly di- minishes the number of the blood corpuscles, increases the amount of water, slightly diminishes the albumen, but in no way affects the fibrin, extractive matters, or salts. 2d, That plethora is a simple increase of all the constituents of the blood. 3d, That anaemia is in truth a mis- nomer, but is used in the sense of a diminished number of the corpuscles, or spanaamia. 4th, That inflammation increases the amount of the fibrin from 3 to 10 in 1000 parts, doubles the quantity of cholesterine, and diminishes the albumen. 5th, That the fibrin is diminished in fevers, exanthematous disorders, intoxication, starvation, and purpura haamorrhagica. 6th, When any secretion is checked, its essential prin- ciples accumulate in the blood. 7th, The albumen of the blood is diminished in Bright's disease, in cardiac dropsy, and in puerperal fever. These conclusions, founded on a large number of data, are most im- portant, and. as we shall subsequently see, while opposed to former views of medical practice, especially in acute inflammatory diseases, com- pletely harmonize with the results of modern experience. 5. The Excretion of the Effete Matters from the Body in Various Forms and by Different Channels. The matters admitted into the blood as the result of the secondary digestion circulate with that fluid, but are soon separated from it in various forms, to be conducted out of the system by different channels. 1st, In the form of carbonic acid and watery vapor by the lungs. 2d, Through the liver, and this in the form of bile, fat, and hydrated starch, whereby a large amount of hydro-carbon is excreted. Of the bile we have already spoken. Fat is found in considerable quantity in the liver, giving rise, in cases where there is excess of heat and food with little exercise, to a want of balance between the hepatic and pulmonary excretions. Thus fatty liver is found in all stall-fed animals, and fa likely to be present among Europeans in India, and drunkards at home. 134 PRINCIPLES OF MEDICINE. Lastly, it has been shown by Bernard that a large quantity of hydrated starch (glycogen) is continually forming in the liver, which, he thinks, on contact with the blood, is transformed into sugar, and in health is sepa- rated as carbonic acid by the lungs. If this be in excess, or if the action of the lungs be defective, it passes off as sugar by the kidneys, constitut- ing diabetes. This view, though supported with great ingenuity, and apparently unanswerable experimental arguments, has recently been questioned by Dr. Pavy, who has endeavored to show that the phe- nomena described by Bernard are post mortem, and do not occur in the living animal (see Diabetes.) But however the products of the liver may ultimately pass out of the system, its chief function must be regarded as excretory. 3d, Through the kidneys there pass off from the body a large amount of water, of earthy salts, and especially two compounds rich in nitrogen—viz., urea and uric acid. These constituents may be derived from either the primary or secondary digestion ; so that the functions of the kidneys are altogether excretory. 4th, The skin is constantly excreting water and oil, a minute quantity of carbonic acid, and a mass of gelatine and horny matter, in the form of epidermis, hair, nail, and other integumentary appendages. 5th and lastly, In addition to the residue of the food, there are dis- charged from the bowels fatty and earthy matters. The amount of excretory matters separated in this way may be esti- mated as follows:—Of carbonic acid there are given off about two pounds, or seven cubic feet, of which an ounce and a half may be separated by the skin. Of water there are about six pounds separated, one half by the urine and faeces, and the other half by the lungs and skin. The urine contains ten times as much as the faeces; and the skin gives oft twice as much as the lungs or somewhat more. As it is calculated that only five pounds pass into the body mixed with the fluid, the extra pound is supposed to be .formed in the system by the union of oxygen with water. Of urea an ounce is separated in the urine daily of an adult man, together with eight or ten grains of uric acid. It is by these substances, which contain about fifty per cent of nitrogen, that the azote which enters the body is almost altogether separated from it. The earthy salts pass out in minute quantity dissolved in the sweat, and are given off more largely by the urine, which contains daily four drachms and a half of chloride of sodium, four drachms of sulphate of soda and potash, two drachms of acid phosphate of soda, and one drachm of phosphate of lime and magnesia. In the faeces another four or six drachms of mineral matter may be passed daily, the chief portion of which is derived from the residue of the food. Besides the substances named, a certain quan- tity of fatty, coloring, extractive, and other matters is excreted, the amount of which has not been yet estimated. In this way, the albuminous, fatty, and mineral ingredients of the food, after having entered the body to form blood, and through it to build up tissue, is ultimately ejected from the economy, after having undergone a series of histogenetic and histolytic molecular changes, and been metamorphosed by chemical, mechanical, and vital agencies. The HEALTHY AND DISEASED NUTRITION. 135 mode in which this is accomplished is now tolerably well known. Doubtless several points have yet to be determined, and numerous details require investigation. But the great function of nutrition, as I have now placed it before you, may be said to be established in science. In the same manner that the chemist, following Dumas, recognises in nature at large the exchanges which are constantly going on between the mineral, the vegetable, and the animal worlds—the earth and air build- ino- up vegetables : these building up animals, and these on their decom- position being again restored to earth and air—so does the physiologist in each animated creature trace the food through its changes until it is con- verted into tissue, has enjoyed life for a time, and is then decomposed, returning, though in an altered form, to the external world whence it came. The molecular law of development, formerly described, is singularly well illustrated by the function of nutrition as now explained. Food consisting of well-formed organic matter, animal and vegetable, is disin- tegrated by the primary digestion. The histolytic molecules so produced become histogenetic ones, and build up the blood corpuscles. These are in turn disintegrated and dissolved to form the liquor sanguinis, but once more other molecules are obtained from it to keep up the growth of the tissues, whether nutritive or secretory. The histogenetic molecules so produced are again rendered histolytic by the secondary digestion, and, circulating in the blood, undergo various combinations before being excreted from the economy. In this manner the great function of nutri- tion is shown to be essentially molecular. Animal Bleat.—We must not forget that the changes we have re- ferred to—that is to say, the various metaphormoses of the tissues and their chemical combinations—produce the animal heat of the body. One of the most important contributions to science of Liebig is unques- tionably the demonstration that the union of oxygen with the blood in the lungs, and the formation of carbonic acid in the capillaries united, produce sufficient heat to account for what is found in the animal body. Other causes, however, co-operate, among which muscular contraction is important. Helmholz has shown that heat is thereby generated in con- tractile muscle recently cut from the animal, and therefore unconnected with a circulation. These metaphormoses further produce the force and energy which are applied in so many forms and combinations to maintain the physical and vital actions of the economy. From the foregoing considerations, it follows that an eliminative function is to a certain extent brought about by all the processes of growth referred to, and that there can be no change, however limited, that is not necessarily associated with a general one in the system at large. As all the nutritive functions are connected with one another, an excess or diminution of local growth, by subtracting from or adding to the constituents of the blood, must produce an alteration in that fluid both as to quantity and quality. The idea of Treviranus, viz., " that each single part of the body, in respect of its nutrition, stands to the whole body in the relation of an excreted substance," has been ably shown by Mr. Paget to account for various processes in health, under the name of " complemental nutrition." * The same notion has been, still. * Lectures on Surgical Pathology. Lecture 2. 13G PRINCIPLES OF MEDICINE. further extended by Dr. William Addison, who correctly points out, that in the distinctive eruptive fevers, such as small-pox, the numerous minute abscesses in the skin eliminate the morbid poison, which formerly existed in the blood, and are in this way essential to the cure. This provident action he denominates " cell therapeutics." * Hence they are fixed pro- cesses in abnormal as in normal nutrition, with which it is essential for the medical practitioner to be acquainted, in order that, instead of oper- ating blindly or empirically, he may act scientificall}*, or in accordance with natural laws. Further we cannot avoid observing that the process of nutrition is a continuous round, which in the natural world may be said to commence with the reception and terminate with the preparation of aliment, vege- table or animal; that this is observable not only in the " chemical balance of organic nature," so beautifully described by Dumas, but in the incessant chemical compositions and decompositions, as well as structural formations and disintegrations, which are peculiar to all vital entities. If so, it must be apparent that our knowledge of the animal economy, and of the diseases to which it is liable, can only be elucidated by investigating the nature of such chemical and structural changes, together with the necessary relations that each one bears to the others; and that it is on such kind of knowledge alone that medicine, as a scientific art, can ever repose in security. Yie can now readily understand how derangement in one stage of the nutritive process more or less affects the others. Thus, if alimentary matters are not furnished in sufiicient quantity, and of a proper quality, the blood is rendered abnormal, and it necessarily follows that the matters it gives off will be abnormal also, and its subsequent transforma- tions more or less modified. Again, if secretion be checked, the blood is not drained of its effete matter; and if excretion be prevented, the secre- tions themselves may enter the blood, and act upon it as a poison. A deceased or morbid state of the blood, therefore, may arise from either of the stages of nutrition which we have described being rendered irregular, or otherwise abnormal. In whatever part of the circle inter- ruption takes place, it will, if long continued, affect the whole. Thus, a bad assimilation of food produces through the blood bad secretions and excretions, whilst an accidental arrest of one of the latter reacts through the blood on the assimilating powers. The forms of disease thus arising may be endless, but as regards nutrition, they may all be traced to the following causes :— 1. An improper quantity or quality of the food. 2. Circumstances preventing assimilation or impeding respiration. 3. Altered quantity or quality of nutritive matters passing out of the blood. 4. The accumulation of effete matters in the blood. 5. Obstacles to the excretion of these from the body. Examples in which each of these causes, separately or combined, have occasioned disease, must have occurred to every practitioner. It is true that all general diseases are accompanied by certain changes in the * Addison on Cell Therapeutics. 1856. HEALTHY AND DISEASED INNERVATION. 137 blood, but these changes are to be removed, not by operating on that fluid directly, but by obviating or removing those circumstances which have deranged the stage of nutrition primarily affected. For instance, a very intense form of disease may be produced in infants, through im- proper lactation. The remedy is obvious; we procure a healthy nurse. Ischuria is followed by coma, in consequence of the accumulation of urea in the blood; we give diuretics to increase the flow of urine, and the symptoms subside. In the one case we furnish the elementary principles necessary for nutrition; in the other, we remove the residue of the pro- cess. In both cases the blood is diseased, but its restoration to health is produced by acting on a knowledge of the causes which led to its derangement. v In the same manner we might illustrate the indications for correct practice in the other classes, of causes tending to derange the blood. Thus, although there be a proper quantity or quality of food, there may be circumstances which impede its assimilation ; for instance, a too great acidity or irritability of the stomach—the use of alcoholic drinks— inflammation or cancer of the organ. It is the discovery and removal of these that constitute the chief indications for the scientific practitioner. Again, the capillary vessels become over-distended with blood, and the exudation of liquor sanguinis to an unusual amount takes place, con- stituting inflammation. How is this to be treated ? In the early stage topical bleeding, if directly applied to the part, may diminish the con- gestion, and the application of cold will check the amount of exudation. But the exudation having once coagulated outside the vessels, acts as a foreign body, and the treatment must then be directed to furthering the transformations which take place in it, and facilitating the absorption and excretion of effete matter. This is accomplished by the local appli- cation of heat and moisture—the internal use of neutral salts to dissolve the increase of fibrin in the blood, and the employment of diuretics and purgatives to assist its excretion by urine or stool. The general principle we are anxious to establish from this general sketch of the nutritive functions is—that diseases of nutrition and of the £ blood are only to be combated by an endeavor to restore the deranged processes to their healthy state, in the order in which they were impaired; that a knowledge of the process of nutrition is a preliminary step to the proper treatment of these affections ; that the theory of acting directly on the blood is incorrect; and that an expectant system is as bad as a purely empirical one. OF THE GENERAL LAWS OF INNERVATION IN HEALTH AND DISEASE. The function of innervation is also made up of the performance of various actions, widely different from each other, although associated together. These actions lead to the manifestation of intelligence, sensa- tion, and combined motion. But as the connection between these is not capable of exhibiting such an order of sequence as has been made appa- 138 PRINCIPLES OF MEDICINE. rent among the nutritive processes, it will be necessary to describe them in a different manner. • General Anatomy and Physiology of the Nervous System. Structure and Arrangement of the Nervous System.—To the eye, the nervous system appears to be composed of two structures— the grey or ganglionic, and the white or fibrous. The ganglionic, when examined under high powers, may be seen to be composed of nucleated cells, vary- ing greatly in size and shape, mingled with a greater or less number of nerve tubes, also varying in calibre. One important fact with regard to these corpuscles is, that many of them may be demonstrated to throw out prolongations, which may be seen in well-preserved preparations to be in direct communication with the central band or axis of Remak and Purkinje within the fibres. The so-called fibres, indeed, may be shown to consist of minute tubes, which are smallest towards the periphery of the cerebrum, larger towards its base, and largest in the nerves. They are of three kinds—1st, Finely cylindrical, as observed in the optic and auditory nerves; 2d, Varicose, as in the white substance of the cerebral lobes and of the spinal cord ; and 3d, Larger and of regular size through- out, as in the nerves. There are also bundles of gelatinous or flat fibres, the nature of which is much disputed, very common in the olfactory nerve and sympathetic system of nerves. The general arrangement of the two kinds of structures should be known. By cerebrum, or brain proper, ought to be understood that part of the encephalon constituting the cerebral lobes, situated above and outside the corpus callosum; by the spinal cord all the parts situated below this great commissure, consisting of the corpora striata, optic thalami, corpora quadrigemina, cerebellum, pons varolii, medulla oblon- gata, and medulla spinalis. In this way, we have a cranial and a verte- bral portion of the spinal cord. In the cerebrum, or brain proper, the ganglionic or corpuscular structure is external to the fibrous or tubular. It presents on the sur- face numerous anfractuosities, whereby a large quantity of matter is capable of being contained in a small space. This crumpled-up sheet of grey substance has been appropriately called the hemispherical ganglion (Solly). In the cranial portion of the spinal cord, the grey matter exists in masses, constituting a chain of ganglia at the base of the encephalon, more or les3 connected with each other and with the white matter of the brain proper above, and the vertebral portion of the cord below. In this last part of the nervous system the grey matter is in- ternal to the white, and on a transverse section presents the form of the letter x, having two posterior, and two anterior cornua—an arrangement which allows the latter to be distributed in the form of nerve tubes to all parts of the frame. The white tubular structure of the vertebral portion of the cord is divided by the anterior and posterior horns of grey matter, together with the anterior and posterior sulci, into three divisions or columns on each side. On tracing these upwards into the medulla oblongata, the ante- HEALTHY and diseased innervation. 139 rior and middle ones may be seen to decussate there with each other, whilst the posterior columns do not decussate. On tracing the columns up into the cerebral lobes, we observe that the anterior,-or pyramidal tracts, send off a bundle of fibres, which passes below the olivary body, and is lost in the cerebellum—(Arciform band of Solly). The principal portion of the tract passes through the corpus striatum, and anterior portion of the optic thalamus, and is ultimately lost in the white sub- stance of the cerebral hemispheres. The middle column, or olivary tract, maybe traced through the substance of the optic thalamus and corpora qua- drigemina, to be in like manner lost in the cerebral hemispheres. The pos- terior column, or restiform tract, passes almost entirely to the cerebellum. In addition to the diverging fibres in the cerebral hemispheres which may be traced from below upwards, connecting the hemispherical ganglion with the structures below, the brain proper also possesses bands of transverse fibres, constituting the commissures connecting the two hemispheres of the brain together, as well as longitudinal fibres connecting the anterior with the posterior lobes. In the posterior columns of spinal cord it results from the investigations of Lockhart Clarke, that there is a decussation of various bundles of fibres through- out its whole extent. It is now also determined, that many of the fibres in the nerves may be traced directly into the grey substance of the cord —a fact originally stated by Grainger, but confirmed by Budge and Kolliker. Further, it has recently been shown, that by means of these fibres an anastomosis is kept up between the various columns, even those on both sides of the cord, through the medium of nerve cells in the grey matter, an important fact principally demonstrated by the labors of Stilling, Remak, Van der Kolk, Lockhart Clarke, and others. These later observations, indeed, render it certain that the numerous actions hitherto called reflex are truly direct, and are carried on by a series of nervous filaments running in different directions through the cord; and hence the term diastaltic, proposed by Marshall Hall instead of reflex, is in every way more appropriate. Functions of the Nervous System.—The great difference in structure existing between the grey and white matter of the nervous system, would, apriori, lead to the supposition that they performed separate functions. The theory at present entertained on this point is, that, while the grey matter eliminates or evolves nervous power, the white matter simply conducts to and from this ganglionic structure the in- fluences which are sent or originate there. Cerebrum.—This portion of the nervous system consists of that mass of grey and white matter situated above and outside the corpus callosum, composing what are denominated the two cerebral lobes. On carefully examining a thin section of this structure, prepared after the manner of Lockhart Clarke, and steeped in carmine, the white substance in the adult may be seen to be composed wholly of nerve tubes. These become more and more minute as they reach the grey matter of the convolutions, and are gradually lost in it. The layer of grey matter consists of a finely molecular substance, in which are embedded minute nerve cells, varying in shape and size. The cerebral lobes furnish the conditions necessary for the manifesta- 140 PRINCIPLES OF MEDICINE. tion of the intellectual faculties properly so called, of the emotions and passions, of volition, and are essential to sensation. That the evolution of the power especially connected with mind is dependent on the hemispherical ganglion, is rendered probable by the following facts:— 1. In the animal kingdom generally, a correspondence is observed between the quantity of grey matter, depth of convolutions, and the sagacity of the animal. 2. At birth, the grey matter of the cerebrum is very defective; so much so, indeed, that the convolutions are, as it were, in the first stage of their formation, being only marked out by superficial fissures almost confined to the surface of the brain. As the cineritious substance increases, the intelligence becomes developed. 3. The results of experiments by Flourens, Rolando, Hertwig, and others, have shown that, on slicing away the brain, the animal becomes more dull and stupid in proportion to the quantity of eortical substance removed. 4. Clinical observation points out, that in those cases in which the disease has been afterwards found to commence at the circumference of the brain, and proceed towards the centre, the mental faculties are affected first; whereas in those diseases which commence at the central parts of the organ, and proceed towards the circumference, they are affected last. The grey matter, therefore, evolves that force or quality which is essential to mind, and the conditions necessary for this are evidently connected with the molecular and cell structure. The white matter, on the other hand, conducts the influences originating in, and going to, the grey matter. These may be said to travel in four directions—1st, Out- wards to the circumference of the body along the nerve tubes; 2d, In- wards and upwards to the hemispherical ganglion; 3d, From one hemi- sphere to another by the commissures; and 4th, From the anterior to the posterior lobes, and vice versa, by the so-called longitudinal fibres of the hemispheres. This power of conducting mental influences in various directions is probably subservient to that combination of faculties which characterises thought. By the term sensibility I understand the peculiar vital property possessed by nervous substance of conducting the influence generated by impressions made upon it. By sensation I understand the mental con- sciousness of such impression. Now the experiments of Flourens, Hertwig, Longet, and others, have shown that on removing the cerebral lobes from animals, the mental faculties, including, of course, conscious- ness and volition, and therefore sensation and voluntary motion, are abolished, while the creature can stand when put on its legs, fly when thrown into the air, and walk when pushed. Hertwig has kept pigeons in this condition for three months, deglutition and all other reflex acts being perfect, the mental faculties only absent. Longet and Dalton have recently maintained that sensation may exist without the cerebral lobes. The former says, when the cerebrum was removed from a pigeon, and a light suddenly brought near its eyes, there was contraction of the pupil, and even winking. Further, when a rotatory motion was given to the candle at such a distance that no heat could operate, the pigeon made a similar movement with its head. But of these facts I would observe that the pupil will contract on the application of light when the eye has been cut out of the head, and a sunflower follows the course of the sun. HEALTHY AND DISEASED INNERVATION. 141 It cannot, therefore, be said that under such circumstances the eye and the flower possess sensation or can see. Daltou's description of what occurs after removal of the cerebrum is as follows:—" The effect of this mutilation is simply to plunge the ani- mal into a state of profound stupor, in which he is almost entirely in- attentive to surrouuding objects. The bird remains sitting motionless upon his perch or standing upon the ground, with the eyes closed and the head sunk between the shoulders. . . . This state of immobility, however, is not accompanied by the loss of sight, of hearing, or of ordi- nary sensibility. All these functions remain, as well as that of voluntary motion. If a pistol be discharged behind the back of the animal, he at once opens his eyes, moves his head half round, and gives evident signs of having heard the report; but he immediately becomes quiet again, and pays no further attention to it. Sight is also retained, since the bird will sometimes fix its eye on a particular object and watch it for several seconds together. Ordinary sensation also remains after removal of the hemispheres, together with voluntary motion. If the foot be pinched with a pair of forceps, the bird becomes partially aroused, moves uneasily once or twice from side to side, and is evidently annoyed at the irritation." From the observed facts Dalton concludes that " the animal is still capable, after removal of the hemispheres, of receiving sensations from external objects. But these sensations appear to make upon him no lasting impression. He is incapable of connecting with his perceptions any distinct succession of his ideas. He hears, for example, the report of a pistol, but he is not alarmed by it; for the sound, though distinctly enough perceived, does not suggest any idea of danger or injury. There is accordingly no power of forming mental associations, nor of perceiving the relation between external objects. The memory, more particularly, is altogether destroyed, and the recollection of sensations is not retained from one moment to another. The limbs and muscles are still under the control of the will, but the will itself is inactive, because apparently it lacks its usual mental stimulus and direction." I think the facts may be interpreted differently and more correctly. The turning round of the animal's head on the explosion of a pistol, and many other movements, may be altogether reflex, dependent on irritations communicated to the cranial portion of the spinal cord through the tympanum. Again, that the pigeon should open its eyes with a vacant stare, or apparently fix them on an object, is no proof of sight. We constantly do these things ourselves with the brain entire, and see nothing. Lastly, that the limbs and muscles are under the control of the will, while the will is inactive, appears to be contradictory language. One of the most active operations of the will is to direct motion; and to say of a bird which flies away on the production of the slightest noise in health, but does not move on the discharge of a pistol, that in the latter case its limbs and muscles are still under the control of the will, appears to be a most unfounded conclusion. The truth evidently is that there is no will, no sensation in such a case, any more than there is in a sensi- tive plant, which shrinks on being touched, but which surely cannot be said to exercise either the one mental faculty or the other. With regard to the relation existing between mind and brain, two 142 PRINCIPLES OF MEDICINE. views are contended for : one, that the brain originates; the other, that it is only the instrument of thought. The discussion is metaphysical rather than physiological, because the phenomena observed in either case are the same, and these depend upon the structure and quality of the organ itself. In this respect the brain is exactly similar to a nerve or muscle. It possesses properties and functions which it is our duty to study. Why it does so we are ignorant, and are content to regard them as ultimate facts in our science. In the same way, therefore, that con- tractility is a property of muscle, sensibility of nerve, growth of tissue, and secretion of gland, so we regard thought as a property of the brain. But to avoid metaphysical subtleties, we are quite willing to say that it furnishes the conditions necessary for the manifestation of mind. From the various facts now known, I think it may be concluded that the cortical substance of the cerebral lobes furnishes those conditions which are necessary for thought, including all mental operations, sensa- tion, and volition. I do not think that in the present state of science we are warranted in proceeding further, for the same facts entirely negative all those theories which have been advanced having for their object a localization of the different faculties into which the mind has been arbi- trarily divided. Some have maintained that volition is seated in one place, memory in a second, sensation in a third, and so on; but we have no sufficiently extended series of facts to establish any of these or of similar propositions. There can be no doubt that the relation between the molecular, nuclear, and cell elements of the hemispherical ganglion, as the instru- ment of mind, must be most important; and yet I am not acquainted with any one, who, having first qualified himself for the task by a pro- longed and careful study of histology, has investigated the brain in cases of insanity. Psychologists content themselves with repeating well-known clinical observations, with the ordinary morbid anatomy or density of the brain, and with the metaphysical speculations which have been pushed as far as, if not further than, human intellect can carry them. Need we feel surprised that the true pathology of insanity is unknown ? What we desiderate is a careful scrutiny of the organ. Hitherto the difficul- ties of such an investigation have been insurmountable, in consequence of our imperfect methods of research. But let any one possessing a com- petent knowledge of histology and the-use of our best microscopes, with the opportunities our large asylums offer, only now dedicate himself to the task, and he may be assured that while extending the bounds of science he will certainly obtain an amount of fame and honor that few can hope to arrive at. The molecules on which muscular contractility depends are, as we have seen, visible molecules, and so I believe are those in the hemispherical ganglion, so essentially connected with the functions of the brain. Cereebllum.^—The ganglionic surface of the cerebellum is structurally altogether unlike that of the cerebrum. On looking at a well-made verti- cal section of the former, prepared after the method of Lockhart Clarke, and steeped in carmine, under a magnifying power of 25 diameters, the fine tubular substance in the centre is seen to be bounded externally by a granular layer, outside which is a row of nerve cells with branched pro- HEALTHY AND DISEASED INNERVATION. 143 cesses gradually terminating towards the margin of the exterior layer, which is finely molecular. On increasing the magnifying power to 250 diameters, we see more distinctly the relation of these various parts to one another, and recognise in the interior of each granule an included rounded body. According to Gerlach, these corpuscles are united, to one another by a slender filament, which he has figured in a hypothetical diagram. Although such an appearance as he has imagined cannot be discovered in the natural structure, I have seen the tubes running between the granules, and traced them to the external margin of the granular layer. The external layer is the structure which demands the greatest attention. It is composed essentially of a finely molecular mass, containing numerous capillaries derived from the vessels of the meninges. Large ganglionic cells external to the granular layer send off branching processes externally, which are gradually lost as they proceed outwards. Both in the external, as well as in the internal granular layer, the basis of the texture is evidently molecular—a fact which hitherto has received far too little attention. If the cerebellum be removed gradually from a pigeon in successive slices, there is progressive circumscription of the locomotive actions. On taking away only the upper layer there is some weakness and a hesitation in its gait. When the sections have reached the middle of the organ the animal staggers much, and assists itself in walking with its wings. The sections being continued further, it is no longer able to preserve its equilibrium without the assistance of its wings and tail; its attempts to fly or walk resemble the fruitless efforts of a nestling, and the slighest touch knocks it over. At last, when the whole cerebellum is removed, it cannot support itself even with the aid of its wings and tail; it makes violent efforts to rise, but only rolls up and down; then, fatigued with struggling, it remains for a few seconds at rest on its back or abdomen, and then again commences its vain struggles to rise and walk. Yet all the while its sight and hearing are perfect. The slightest noise, threat, or stimulus, at once renews its contortions, which have not the slightest appearance of convulsions. These effects, first described by Flourens, have been confirmed by all experimenters, and occur in all animals. The results contrast strongly with those of the much more severe opera- tion of removing the cerebral lobes. " Take two pigeons," says Longet; " from one remove completely the cerebral lobes, and from the other only half the cerebellum ; the next day the first will be firm upon its feet, the second will exhibit the unsteady and uncertain gait of drunkenness." These facts induced Flourens to consider the cerebellum as the co- ordinator of motion, in which view he was supported by the late Dr. Todd and others. Foville, on the other hand, supposed it to be the seat of sensation, and argued that, as it is by means of this function that we regulate muscular motion, so, when it is destroyed, the faculty of per- ceiving the movements being lost, we cannot answer for their precision or duration. That it should be the seat of sensation generally is dis- proved by the fact that the animal is evidently conscious of impressions after its removal; but that it should be the organ of that peculiar sense, which has been variously called " muscular sense," " sense of resistance," and "sense of weight," is very probable. Accordingly we find that 144 PRINCIPLES OF MEDICINE. Professor Lussana of Parma has recently brought together all the argu- ments which exist as to this matter, along with numerous original obser- vations, confirmatory of the view that the cerebellum does indeed regulate motion,' but in consequence of its being the seat of the muscular sense.* It has been suggested by Carpenter and Dunn that the corpus den- tatum in the cerebellum is the ganglion which is connected with this sense—a view rendered improbable by Brown-Sequard's analysis of cases where the organ was diseased. I submit that the function is seated in the external layers of grey matter rather than in the corpus dentatum— a theory to which the same objections do not apply. Mind frequently remains when portions of the hemispherical ganglion are injured, although we know of no instance in which, where the whole of it has been dis- eased, intellect has been preserved. So the co-ordinating motor power may remain when parts only of the cerebellar leaflets are destroyed, but is certainly lost when the whole grey matter is diseased. That the cere- bellum, therefore, is connected with a special sense, through which it influences the co-ordinate action of the muscles, is a doctrine worthy the attention of physiologists. Its external layers of grey matter, constituting a complex ganglionic structure, has probably the same relation to the mus- cular sense as the hemispherical ganglion has to sensation in general. The spinal cord has two portions—a cranial and a vertebral. The former consists of a chain of ganglia more or less connected with one another, as well as with the cerebrum above and the vertebral part of the cord below; the latter is composed of two lateral halves divided by an anterior and posterior fissure. Each half is subdivided into three columns—an anterior, middle, and posterior—by the two cornua of the central mass of grey matter. Through the centre runs the spinal canal, lined with columnar epithelium. The white matter of the lateral columns is composed of tubes, which, as shown by Lockhart Clarke, on being traced inwards from the spinal nerves, join the ganglionic cells in the grey matter, and, through them, keep up a communication—1st, with the opposite lateral columns; 2d, with the cerebrum; and 3d, with the anterior and posterior roots of the nerves. The course of the conducting tubes, as pointed out by Clarke, shows that the views of Sir Charles Bell, though correct as to the functions of the roots of the nerves, were erroneous with regard to the columns of the cord. The few experiments Bell made on those roots confirmed the conclusions be drew from dis- section. Had he experimented on the cord itself, he might have formed juster views. What he neglected, however, was performed by Brown- Sequard, with the effect of demonstrating that a section of the anterior columns does not produce paralysis of voluntary motion, nor section of the posterior columns prevent conduction between the brain and poste- rior roots. To produce either of these results, the section must be con- tinued into the grey matter. If two sections be made, however, midway between two neighboring spinal nerve roots, then conduction between the parts above and below the sections is cut off. The explanation of this is to be found in the course taken by the nerve tubes as shown by Lockhart Clarke, which so diverge from one another, on passing into the cord, that no one transverse section of the column can divide them, * Journal de la Physiologie, tome v., p. 418, ct seq. HEALTHY AND DISEASED INNERVATION. 145 although two at a certain distance from one another may. Thus, histolo- gical research and experimental investigation support oue another, and the two have now demonstrated that the conducting nerve tubes of the spinal roots of the nerves communicate through the grey matter of the cord, not only with the brain and the two sides of the body, but with each other. These facts have served also to explain more fully the nature of those actions variously denominated automatic, reflex, and diastaltic, for the true knowledge of which we are indebted to the labors of Marshall Hall. It is now clear that the influences excited by irritation of nerves run continuously through the cord in certain directions, now communi- cating with muscles to produce spasms, and now with the glands and vessels to produce secretion and vasomotor action, and this without any necessary connection with the brain, and therefore without sensation. Nerves.—The various nerves of the body consist for the most part of nerve tubes, running in parallel lines. Yet some contain ganglionic cor- puscles, as the olfactory and the ultimate expansion of the optic and audi- tory nerves, whilst the sympathetic nerve contains, in various places, not only ganglia, but gelatinous flat fibres. The posterior roots of the spinal nerves possess a ganglion, the function of which is quite unknown. These roots are connected with the posterior horn of grey matter in the cord, while the anterior roots are connected with the anterior horns. As regards function, the nerves may be considered as—1st, Nerves of special sensation, such as the olfactory, optic, auditory, part of the glosso- pharyngeal and lingual branch of the fifth. 2d, Nerves of common sen- sation such as the greater portion of the fifth, and part of the glosso- pharyngeal. 3d, Nerves of motion, such as the third, fourth lesser division of the fifth, sixth, facial, or portio dura of the seventh, and the hypo-glossal. 4th, Senso-motory or mixed nerves, such as the pneumo- gastric, the accessory, and the spinal nerves. 5th, Sympathetic nerves. All nerves are endowed with a peculiar vital property called excita- bility, inherent in their structure, by virtue of which they may be excited on the application of appropriate stimuli, so as to transmit the influence of the impressions they receive to or from the brain, spinal cord, o^ftgrtain ganglia, which may be considered as nervous centres. The nei ?,ft of special sensation convey to their nervous centres the influence of impressions caused by odoriferous bodies, by light, sound, and by sapid substances. The nerves of common sensation convey to their nervous centres the influence of impressions caused by mechanical or chemical substances. The nerves of motion carry from the nervous centres the influence of impressions, whether psychical or physical (Todd). The mixed nerves carry the influence of stimuli both to and from, thus combining in themselves the powers necessary for the functions of com- mon sensation and of motion. But there are doubtless numerous other individual nerve tubes pecu- liarly qualified to receive impressions connected with particular sensations —such, for example, as those of cold or warmth, of weight, of hunger, thirst, and numerous other feelings—which, although not yet actually discovered, must have relation to the special endowments of these tubes. As to the direction in which these influences travel, we now know that they pass, first, from the brain to the voluntary muscular system gen- 10 146 PRINCIPLES OF MEDICINE. erally; second, from the surface and the organs of sense to the brain; third, from one side of the body to the other, through the spinal cord ; fourth, from the cerebro-spinal system through ganglia to numerous glands, non-voluntary muscles, and to the blood-vessels. There may be other directions in which nervous influence travels, but such have not yet been discovered. In the meantime we know that the nerve tubes are not only idio-motor and sensitive (general and special), but diastal- tic, nutritive, secretory, and vaso-motor. The ganglionic system of nerves consists of numerous ganglia havhig connecting filaments, keeping up a communication with each other and with the cerebro-spinal centres. These communications are not direct, the various nerve tubes separating in a ganglion, and, whether they do or do not anastomose with nerve cells, on leaving it form a different combination of nerves. Hence every ganglion serves to break the con- ducting power of the nerves, or to modify it—probably both. In health we are not conscious of the actions of internal viscera principally supplied with these nerves, nor can volition act on muscular parts to which they are distributed. But let them be diseased, and they often excite excru- ciating yet peculiar pain, as in that caused by angina, by colic, or by a gall-stone. Again, mental emotions have a powerful influence on the contractions of the organic contractile tissue, as in palpitations of the heart, or as visible in blood-vessels on the production of pallor or of a blush. In the same manner mental emotions or desires act on the vari- ous glands, exciting or diminishing their action. Such results can only be explained by the connection known to exist between these nerves and the spinal cord. Similar phenomena may be produced by direct stimu- lation or by reflex action, each ganglion being a centre through which afferent and efferent nerves communicate—the whole constituting an excito-nutrient and excito-secretory system, as has been well described by Dr. Campbell of the United States.* The observations as to the effects of injuring the trunk of the gan- glionic system, more especially in the neck, have excited the attention of numerous physiologists since the days of Petit in 1727, and more espe- cially of Dupuy (1816), Breschet (1837), John Reid (1838), Biffi (1846), Budge and Waller (1851), and finally of Bernard and BrowfY-Sequard (1852). Bernard discovered the remarkable increase of heat which fol- lowed section of the nerve, and Brown-Sequard showed that cold was produced on applying galvanism to it. It is now recognised that if we cut the trunk of the sympathetic, heat commences in the neighboring parts almost immediately, and will continue for weeks without producing inflammation, oedema, or other effect, so long as the animal remains in good condition. But if it falls sick, either spontaneously or in conse- quence of other operations, the nasal and ocular mucous membranes of the affected side become red and swollen, and secrete pus in great abun- dance. The inflammation of the conjunctiva described by Dupuy, J. Reid, and others, is therefore an accidental phenomenon produced by the debility of the animal, and may be avoided by giving it food and sup- porting its strength. * Essays on the Secretory and Excito-Secretory System of Nerves, etc. Phila- delphia. 185V. HEALTHY AND DISEASED INNERVATION. 147 Thus in the same manner that when we irritate a sensitive nerve we excite motion through a motor nerve, or secretion and nutrition through (ha nerves distributed to glands or to the tissues, so we excite cold by irritating the ganglionic system of nerves, and heat by destroying their action or exhausting it. These phenomena are those of fever. Sensation may be defined to be the consciousness of an impression, and that it may take place, it is necessary—1st, That a stimulus should be applied to a sensitive nerve, which receives an impression ; 2d, That, in consequence of this impression, a something, which we designate an influence, should be generated, and conducted along the nerve to the hemispherical ganglion; 3d, On arriving there, it calls into action that faculty of the mind called consciousness or perception, and sensation is the result. It follows that sensation may be lost by any circumstance which destroys the sensibility of the nerve to impressions; which im- pedes the progress of the influence generated by these impressions; or, lastly, which renders the mind unconscious of them. Illustrations of how sensation may be affected in all these ways must be familiar to you, from circumstances influencing the ultimate extremity of a nerve, as on exposing the foot to cold; from injury to the spinal cord, by which the communication with the brain is cut off; or from the mind being inat- tentive, excited, or suspended. The independent endowment of nerve is remarkably well illustrated by the fact, that whatever be the stimulus which calls their sensibility iuto action, the same result is occasioned. Mechanical, chemical, galvanic, or other physical stimuli, when applied to the course or the extremities of a nerve, cause the very same results as may originate from suggestive ideas, perverted imagination, or other psychical stimuli. Thus a chemi- cal irritant, galvanism, or pricking and pinching a nerve of motion will cause convulsion and spasms of the muscles to which it is distributed. The same stimuli applied to a nerve of common sensation will cause pain, to the optic nerve flashes of light, to the auditory nerve ringing sounds, and to the tip of the tongue peculiar tastes. Again, we have lately had abundant opportunities of seeing that suggestive ideas, or stimuli arising in the mind, may induce peculiar effects on the muscles, give rise to pain or insensibility, and cause perversion of all the special senses.—(See Section on General Therapeutics.) Motion is accomplished through the agency of muscles, which are endowed with a peculiar vital property, called contractility, in the same way that nerve is endowed with the property of sensibility. Contractility may be called into action altogether independent of the nerves (Haller), as by stimulating an isolated muscular fasciculus directly (Weher). It may also be excited by a physical or psychical stimulus, operating through the nerves. Physical stimuli (as pricking, pinching, galvanism, etc.) applied to the extremities or course of a nerve, may cause convulsion of the parts to which the motor filaments are distributed directly, or they may induce combined movements in other parts of the body diastaltically (Marshall Hall)—that is, through the spinal cord. In this latter case the following series of actions take place :—1st, The influence of the im- pression is conducted to the spinal cord by the afferent or esodic filaments which enter the grey matter. 2d, A motor influence is transmitted out- 148 PRINCIPLES OF MEDICINE. wards by one or more efferent or exodic nerves. 3d, This stimulates the contractility of the muscles to which the latter are distributed, and motion is the result. Lastly, contractility may be called into action by psychical stimuli or mental acts—such as by the will and by certain emotions. Integrity of the muscular structure is necessary for contractile movements; of the spinal cord, for diastaltic or reflex movements; and of the brain proper, for voluntary or emotional movements. Thus, then, we may consider that the brain acting alone furnishes the conditions necessary for intelligence; the spinal cord acting alone fur- nishes the conditions essential for the co-ordinate movements necessary to the vital functions: and the brain and spinal cord acting together furnish the conditions necessary for voluntary motion and sensation. The following aphorisms will be found useful in endeavoring to reason correctly on the functions of the nervous system: 1. The brain proper is that portion of the encephalon situated above the Corpus Callosum. 2. The spinal cord is divided into a cranial and a vertebral portion. 3. The grey matter evolves and the white conducts nervous power. 4. Contractility is the property peculiar to fibrous texture, whereby it is capable of shortening its fibres. Motion is of three kinds, contractile, dependent on muscle—diastaltic, dependent on muscle and spinal cord— voluntary, dependent on muscle, spinal cord, and brain. „ 5. Sensibility or excitability is the property peculiar to nervous tex- ture, whereby it is capable of receiving impressions. Sensation is the consciousness of receiving such impressions. General Pathology of the Nervous System. For the purposes of diagnosis and treatment, it is a matter of great importance to attend to the following pathological laws which regulate diseased action of the nervous centres. (1.) The amount of fluids within the cranium must alivays be the same so long as its osseous ivalls are capable of resisting the pressure of the atmosphere. There are few principles in medicine of greater practical importance than the one we are about to consider,—the more so, as many able practitioners have lately abandoned their former opinions on this head, and on what I consider to be very insufficient grounds. On thirf point, therefore, I cannot do better than condense and endeavor to put clearly before you the forcible arguments of the late Dr. John Reid, with such other considerations as have occurred to myself. That the circulation within the cranium is different from that in other parts of the body, was first pointed out by the second Monro. It was tested experimentally by Dr. Kellie of Leith, ably illustrated by Dr. Abercrombie, and successfully defended by Dr. John Reid. The views adopted by these distinguished men were, that the cranium forms a spherical bony case capable of resisting the atmospheric pressure, the only openings into it being the different foramina by which the vessels, nerves, and spinal cord pass. The encephalon, its membranes, and blood- vessels, with perhaps a small portion of the eerebro-spinal fluid, com- HEALTHY AND DISEASED INNERVATION. 149 pletely fill up the interior of the cranium, so that no substance can be dislodged from it without some equivalent in bulk taking its place. Dr. Monro used to point out, that a jar, or other vessel similar to the cranium, with unyielding walls, if filled with any substance, cannot be emptied without air or some substance taking its place. To use the illustration of Dr. Watson, the contents of the cranium are like beer in a barrel, which will not flow out of one opening unless provision be made at the same time that air rushes in. The same kind of reasoning applies to the spinal canal, which, with the interior of the cranium, may be said to constitute one large cavity, incompressible by the atmospheric air. Before proceeding further, we must draw a distinction between pressure on, and compression of, an organ. Many bodies are capable of sustaining a great amount of pressure without undergoing any sensible decrease in bulk. By compression must b3 understood, that a substance occupies less spaca from the application of external force, as when we squeeze a sponge, or compress a bladder filled with air. Fluids generally are not absolutely incompressible, yet it requires the weight of one atmosphere, or fifteen pounds on th3 square inch, to produce a diminution equal to __!__ th part of the whole. Now this is so exceedingly small a change upon a mass equal in bulk to the brain, as not to be appreciable to our senses. Besides, the pressure on the internal surface of the blood-vessels never exceeds ten or twelve pounds on the square inch during the most violent exertion, so that, under no possible circumstances, can the contents of the cranium be diminished even the jjho^ part. When the brain is taken out of the cranium, it may, like a sponge, be compressed, by squeezing fluid out of the blood-vessels; but during life, surrounded, as it is, by unyielding walls, this is impossible. For let us, with Aber- crombie, say, that the whole quantity of blood circulating within the cranium is equal to 10, this is 5 in the veins, and 5 in the arteries; if one of these be increased to 6, the other must be diminished to 4, so that the same amount, 10, shall always be preserved. It follows, that when fluids are effused, blood extravasated, or tumors grow within the cranium, a corresponding amount of fluid must be pressed out, or of brain absorbed, from the physical impossibility of the cranium holding more matter. At the same time, it must be evident that an increased or diminished amount of pressure may be exerted on the brain, proportioned to the power of the heart's contraction, the effect of which will be, not to alter the amount of fluids within the cranium, but to cause, using the words of Abercrombie, " a change of circulation" there. This is all, it seems to me, that is shown by the ingenious experiments of Donders, who saw venous con- gestion through glass plates fixed in the crania of rabbits.* Dr. Kellie performed numerous experiments on cats and do^s, in order to elucidate this subject. Some of these animals were bled to death by opening the carotid or femoral arteries, others by opening the jugular veins. In some the carotids were first tied, to diminish the quantity of blood sent to the brain, and the jugulars were then opened, with the view of emptying the vessels of the brain to the greatest possible extent; while, in others, the jugulars were first secured, to prevent as much as possible the return of the blood from the brain, and one of the * Nederlandeche Lancet, 1850. 150 PRINCIPLES OF MEDICINE. carotids was then opened. He inferred, from the whole inqiiry, which was conducted with extreme care, " That we cannot, in fact, lessen, to any considerable extent, the quantity of blood within the cranium by arteriotomy or venesection; and that when, by profuse haemorrhages, de- structive of life, we do succeed in draining the vessels within the cranium of any sensible portion of red blood there is commonly found an equivalent to this spoliation in the increased circulation or effusion of serum, serving to maintain the plenitude of the cranium." Dr. Kellie made other experiments upon the effects of position imme- diately after death from strangulation or hanging. He also removed a portion of the unyielding walls of the cranium in some animals, by means of a trephine, and then bled them to death; and the differences between the appearances of the brain in these cases, and in those where the cranium was entire, were very great. One of the most remarkable of these differ- ences was its shrunk appearance, in those animals in which a portion of the skull was removed, and the air allowed to gravitate upon its inner surface. He says:—" The brain was sensibly depressed below the cra- nium, and a space left, which was found capable of containing a tea- spoonful of water." It results from these inquiries, that there must always be the same amount of fluids within the cranium so long as it is uninjured. In morbid conditions these fluids may be blood, serum, or pus; but in health, as blood is almost the only fluid present (the cerebro-spinal fluid being very trifling), its quantity can undergo only very slight alterations. There are many circumstances, however, which occasion local congestions in the brain, and consequently unequal pressure on its structure, in which case another portion of its substance must contain less blood, so that the amount of the whole, as to quantity, is always preserved. These circum- stances are mental emotions, haemorrhages, effusions of serum, and morbid growths. Such congestions, or local hyperhemias, in themselves constitute morbid conditions; and nature has, to a great extent, provided against their occurrence under ordinary circumstances, by the tortuosity of the ar- teries and the presence of the cerebro-spinal fluid, described by Magendie. The views now detailed had been very extensively admitted into pathology, when Dr. Burrows, of St. Bartholomew's Hospital, endeavored to controvert them, first in the Lumleian lectures of 1843, and subse- quently in a work published in 1846, entitled "On Disorders of the Cerebral Circulation, and on the connections between Affections of the Brain and Diseases of the Heart." Dr. Burrows, however, evidently misunderstood the doctrine we are advocating. Thus, he is always com- bating the idea that blood-letting, position, strangulation, etc., cannot affect the blood in the brain ; whereas the real proposition is, that they cannot alter the fluids within the cranium. By thus confounding blood with fluid, and brain with cranium, he has only overthrown a doctrine of his own creation. Dr. Burrows has brought forward several observations and experi- ments, which he considers opposed to the theory now advocated. His facts are perfectly correct. I myself have repeated his experiments on rabbits, and can confirm his descriptions. It is the inferences he draws from them that are erroneous. For the paleness which results from HEALTHY AND DISEASED INNERVATION. 151 haemorrhage, and the difference observable in the color of the* brain, when animals, immediately after death, are suspended by their ears or by their heels, is explicable by the diminished number of colored blood particles in the one case, and by their gravitation downwards in the other. That the amount of fluid within the cranium was in no way affected, is proved by the plump appearance of the brains figured by Dr. Burrows, and the total absence of' that shrunken appearance so well described by Dr. Kellie. Neither does our observation of what occurs in asphyxia or apncea, oppose the doctrine in question, as Dr. Burrows imagines, but rather confirms it. On this point the following observations by Dr. John Reid are valuable. He says—" If any circumstance could produce congestion of the vessels within the cranium, it would be that of death by hanging; for then the vessels going to and coming from the brain are, with the exception of the vertebral arteries, compressed and then obstructed. These two arteries, which are protected by the peculiarity of their course through the foramina of the transverse processes of the cervical vertebras, must continue for a time to force their blood upon the brain, while a comparatively small quantity only can escape by the veins. Indeed, the greater quantity of blood carried to the encephalon by the vertebrals returns by the internal jugulars, and not by the vertebral veins, which are supplied from the occipital veins of the spinal cord; and the anasto- moses, between the cranial and vertebral sinuses, could carry off a small quantity of the blood only, transmitted along such large arteries as the vertebrals. And yet it is well known that there is no congestion of the vessels within the cranium after death by hanging, however gorged the external parts of the head may be by blood and serum." This is admit- ted by Dr. Burrows, although he endeavors to get rid of so troublesome a fact by a gratuitous hypothesis, which will not bear a moment's exa- mination, but for the refutation of which I must refer to the works of Dr. Reid* On the whole, whether we adopt the terms of local congestion, of change of circulation within the cranium (Abercrombie), or of unequal pressure (Burrows), our explanation of the pathological phenomena may be made equally correct, because each of these, modes of expression im- plies pretty much the same thing. But if we imagine that venesection will enable us to diminish the amount of blood in the cerebral vessels, the theory points out that this is impossible, and that the effects of bleeding are explained by the influence produced on the heart, the altered pressure on the brain, exercised by its diminished contractions, and the change of circulation within the cranium thereby occasioned. I have entered somewhat fully into this theory, because, independent of its vast importance in a practical point of view, it is one which origi- nated in the Edinburgh School of Medicine. Singular to say, notwith- standing the obvious errors and fallacies in Dr. Burrows' work, no sooner did it appear, than the whole medical press of England and Ireland adopted its conclusions, and even Dr. Watson, in the two last editions of his excellent work, also abandoned the theory of Monro, Kellie, and Abercrombie. But so far is this theory concerning the circulation within * Physiological, Anatomical, and Pathological Researches, No. XXV. 152 PUINCIPLES OF MEDICINE. the cranium from being shaken by the attack of Dr, Burrows, that it may be said now to stand on a firmer basis than ever, owing to that attack having drawn forth the convincing reasoning and unanswerable argu- ments of so sound an anatomist, physiologist, and pathologist, as the late Dr. John Reid. (2.) All the functions of the nervous system may be increased, perverted, or destroyed, according to the degree of stimidus or disease operating on its various parts.—Thus, as a general rule, it may be said, that a slight stimulus produces increased or perverted action ; whilst the same stimu- lus, long continued or much augmented, causes loss of function. All the various stimuli, whether mechanical, chemical, electrical, or psychical, produce the same effects, and in different degrees. Circumstances influencing the heart's action, stimulating drinks or food, act in a like manner. Thus, if we take the effects of alcoholic drink, for the purpose of illustration, we observe that, as' regards combined movements, a slight amount causes increased vigor and activity in the muscular system. As the stimulus augments in intensity, we see irregular movements occa- sioned, staggering, and loss of control over the limbs. Lastly, when the stimulus is excessive, there is complete inability to move, and the power of doing so is temporarily annihilated. With regard to sensibility and sensation, we observe cephalagia, tingling, and heat of skin, tinnitus aurium, confusion of vision, muscae volitantes, double sight, and lastly, complete insensibility and coma. As regards intelligence, we observe at first rapid flow of ideas, then confusion of mind, delirium, and lastly, sopor and perfect unconsciousness. In the same manner pressure, me- chanical irritation, and the various organic diseases, produce augmented, perverted, or diminished function, according to the intensity of the sti- mulus applied, or amount of structure destroyed. Then it has been shown that excess or diminution of stimulus, too much or too little blood, very violent or very weak cardiac contractions, and plethora or extreme exhaustion, will, so far as the nervous functions are concerned, produce similar alterations of motion, sensation, and in- telligence. Excessive haemorrhage causes muscular weakness, convul- sions, and loss of motor power, perversions of all the sensations, and lastly, unconsciousness from syncope. Hence the general strength of the frame cannot be judged of by the nervous symptoms, although the treat- ment of these will be altogether different, according as the individual is robust or weak, has a full or small pulse, etc. These similar effects on the nervous centres from apparently such opposite exciting causes, can, it seems to me, only be explained by the peculiarity of the circulation previously noticed. A chauge of circulation within the cranium takes place, and, whether arterial or venous congestion occurs, pressure on some portion of the organ is equally the result. The importance of pay- ing attention to this point in the treatment must be obvious. (3.) The seat of the disease in the nervous system influences the nature of the phenomena or symptoms produced.—It is a matter of very great im- portance to ascertain how far certitude in diagnosis may be arrived at, and the seat of the disease ascertained. On this subject it may be affirmed that, although clinical observation combined with pathology has done much, more requires to be accomplished. As a general rule, it may be HEALTHY AND DISEASED INNERVATION. 153 stated, that disease or injury of one side of the encephalon, especially influences the opposite side of the body. It is said that some very striking exceptions have occurred to this rule, but these at any rate are remarkably rare. Besides, it has always appeared to me probable that, inasmuch as extensive organic disease, if occurring slowly, may exist without producing symptoms, whilst it is certain most important symp- toms may be occasioned without organic disease, even these few excep- tional cases are really not opposed to the general law. Then, as a general rule, it may be said that diseases of the brain proper are more especially connected with perversion and alteration of the intelligence; whilst disease of the cranial portion of the spinal cord and base of the cranium are more particularly evinced by alterations of sensation and motion. In the vertebral portion of the cord, the intensity of pain and of spasm, or else the want of conducting power, necessary to sensation and voluntary motion, indicates the amount to which the motor and sensitive fibres are affected. Further than this we can scarcely generalise with prudence, although there are some cases, as we shall subsequently see, where care- ful observation has enabled us to arrive at more positive results. The fatality of lesions affecting various parts of the nervous centres varies greatly. Thus the hemispheres may be extensively diseased, often without injury to life, or even permanent alteration of function. Con- vulsions and paralysis are the common results of disease of the ganglia, in the cranial portion of the cord. The same results from lesion of the pons varolii. But if the medulla oblongata, where the eighth pair originates, be affected, or injury to this centre itself occur, it is almost always immediately fatal. (4.) The rapidity or slow?iess with which the lesion occurs influences the phenomena or symptoms produced.—It may be said as a general rule, that a small lesion (for instance, a small haemorrhagic extravasation), occur- ring suddenly, and with force, produces, even in the same situation, more violent effects than a very extensive organic disease which comes on slowly. This, however, will depend much upon the seat of the lesion. Very extraordinary cases are on record, where large portions of the nervous centres have been disorganised, without producing anything like the violent symptoms which have been occasioned at other times by a small extravasation in the same place. Here again the nature of the circulation within the cranium offers the only explanation, for the ence- phalon must undergo a certain amount of pressure, if no time be allowed for it to adapt itself to a foreign body; whereas any lesion comino- on slowly enables the amount of blood in the vessels to be diminished ac- cording to circumstances, whereby pressure is avoided. (5.) The various lesions and injuries of the nervous system produce phe- nomena similar in hind.—The injuries which may be inflicted on the ner- vous system, as well as the morbid appearances discovered after death, are various. For instance, there may be an extravasation of blood, exudation of lymph, a softening, a cancerous tumor, or tubercular deposit, and yet they give rise to the same nervous phenomena, and are modified only by the circumstances formerly mentioned, of degree, seat, suddenness, etc. Certain nervous phenomena also are of a paroxysmal character, whilst the lesions supposed to occasion them arc* stationary 154 PRINCIPLES OF MEDICINE. or slowly increasing. It follows, that the effects cannot be explained by the nature of the lesions, but by something which they all have in com- mon ; and this, it appears to me, may consist of—1st, Pressure with or without organic change ; 2d, More or less destruction or disorganisation of nervous texture. Further, when we consider that the same nervous symptoms arise from irregularities in the circulation ; from increased as well as diminished action; sometimes when no appreciable change is found, as well as when disorganisation has occurred—the theory of local congestions to explain functional alterations of the nervous centres seems to me the one most consistent with known facts. That such local con- gestions do frequently occur during life, without leaving traces detectable after death, is certain; whilst the occurrence of molecular changes, or other hypothetical conditions which have been supposed to exist, has never yet been shown to take place under any circumstances. While such appear to me to be some of the generalisations which are important to the physician with regard to the nutritive and nervous functions, viewed separately, it should never be forgotten that he has constantly to do with their conjoint action. Indeed, the derangement cf one order of functions exercises a constant influence over the other, so that in every disease the effects of disordered nutrition are visible in perverted innervation, and the converse. Thus an improper quantity cr quality of food produces sometimes excitement, at others dulness of in- tellect. Various articles of diet have been known to cause violent head- ache and different kinds of nervous phenomena, while starvation, if long continued, excites delirium, paroxysms of mania, and lastly stupor. In children, derangement of the alimentary canal is the most common cause of spasm and convulsion, and in the aged it often leads to apoplexies and palsy. Again, impeded respiration, poverty of the blood, accumulation of effete matters in the system, suppressed secretions and obstructed excretions, are all accompanied or followed by disorders of innervation. On the other hand, the influence of the nervous system on nutrition is equally apparent. Syncope and even death itself have been occasioned by mental emotions. Anxiety and suppressed grief predispose to diseases of the stomach, and thereby to altered nutrition, terminating in various maladies. The reception of joyful or distressing intelligence, it is well known, invigorates or depresses the bodily energies. Various organs are excited to action by particular trains of thoughts or desires, and the countenance is reddened by modesty, and blanched by fear. As a general rule, it may be said, while slight emotions increase the secretions, very violent ones, particularly if suppressed, completely suspend them, and are most dangerous to life.* Direct mechanical injury to the large nervous trunks, in addition to causing paralysis, is now recognised in some cases to produce increased heat and redness in parts, often followed by exudation and ulceration. In chronic cases, such paralysis leads to atrophy, and withering of a limb, or some other portion of the body. Very rarely, injury of a great sympathetic trunk produces similar loss of nutrition without impairment of sensibility or motion, of which * " Give sorrow words ; the grief that will not speak, Whispers the o'erfraught heart, and bids it break."—Shakspeare. INFLAMMATION. 155 the most remarkable example I am acquainted with is recorded by Pro- fessor Romberg of Berlin. It was that of an unmarried woman, aged twenty-eight, in whom, as the result of extensive suppuration on the left side of the neck, which burst through the tonsil, the features on the corresponding side of the face gradually became atrophied, without any di- minution of sensibility or motion. Looking at the two halves of the face sepa- rately, it appeared as if the one belonged to a young, and the other to an old woman. By some it was supposed that the diseased side was sound, and that the other was swollen. The hair, eyebrows, and eye- lashes were very thin on the affected side, and she was in the habit of divid- ing her hair towards the right, so as to equalise the quantity. Every feature, including the brow, eye, nostril, lips, cheek, and chin, as well as the left half of the tongue and Fig. 134 left palatine arch, was smaller than those of the opposite one. Further illustrations of the general principles now detailed will be constantly met with under the head of special diseases. INFLAMMATION. The important morbid change in the animal economy denominated inflammation, is so intimately interwoven with the theory and practice of medicine, that it meets us at the very commencement of our patho- logical inquiries. In all ages it has been made the pivot upon which the medical philosophy of the time has revolved, and any doctrine capable of explaining the various phenomena it presents, cannot but furnish those principles on which our science and art must ultimately rest. I.—Phenomena of Inflammation.—When, with the view of deter- mining the phenomena of inflammation, we sufficiently irritate the trans- parent vascular membrane of some animal—such as the web of the frog's foot—we observe, 1st, An increased rapidity of the circulation in the smaller vessels; 2d, That the same vessels become enlarged, and the current of blood is slower, although even; 3d, That the flow of blood Fig. 134. Remarkable atrophy of tho left side of the face, in a woman aged 28, without loss of sensibility or motion in the affected parts.—(Romberg.) lo6 PRINCIPLES OF MEDICINE. becomes irregular and oscillates; 4th, That the current ceases, and the vessels are distended with colored corpuscles ; and 5th, That the liquor sanguinis is exuded through the walls of the vessels, and that occasionally, in consequence of their rupture, extravasation of blood corpuscles takes place. The first step in the process, viz., narrowing of the capillaries, is readily demonstrated on the application of acetic acid to the web of the frog's foot. If the acid be weak, the capillary contraction occurs more slowly and gradually. If it be very concentrated, the phenomenon is not observed, or it passes so quickly into complete stoppage of blood, as to be imperceptible. Although we cannot see these changes in man under the microscope, certain facts indicate that the same phenomena occur. The operations of the mind, for instance, as fear and fright, and the application of cold, produce paleness of the skin, an effect which can only arise from extraction of the capillaries, and a diminution of the quantity of blood they contain. In the majority of instances, also, this paleness is succeeded by increased redness, the same result as follows from direct experiment on the web of the frog's foot, and which con- stitutes the second step of the process. In other cases, the redness may arise primarily from certain mental emotions, or from the application of beat; and in both instances depends on the enlargement of the capillaries, and the greater quantity of blood which is thus admitted into them.* The variation in the size of the capillaries, and of the amount of blood in them, is conjoined with changes in the movement of that fluid. Whilst the vessels are contracted, the blood may be seen to flow with increased velocity. After a time the blood flows more and more slowly, without, however, the vessel being obstructed : it then oscillates, that is, moves forwards and backwards, or makes a pause, which is evidently synchronous with the ventricular diastole of the heart. At length the vessel appears quite distended with yellow or colored corpuscles, and all movement ceases. Again, these changes in the movement of the blood induce variations in the relation which the blood corpuscles bear to each other, and to the * It has been asserted that instead ot contraction of the capillaries, the first changes observable are enlargement with an increased flow of blood. To determine positively the question of contraction or dilatation, I have made a series of careful observations on the web of a frog's foot. Having fixed the animal in such a way that it could not move, I carefully measured with Oberhaeuser's eye micrometer the diameter of various vessels before, during, and after the application of stimuli. The results were, that immediately hot water was applied, a vessel which measured 13 spaces of the eye micrometer contracted to 10; another that measured 10 contracted to 1; a third that measured 1 contracted to 5 ; a fourth, which was a capillary carrying blood globules in single file, and measured 5, was contracted to 4 ; and another one of the smallest size which measured 4 was contracted to 3. With regard to the ultimate capillaries, it was frequently observed that if filled with corpuscles, they contracted little, but if empty, the contraction took place from 4 to 2, so that no more corpuscles entered them, and they appeared obliterated. This was especially seen after the ad- dition of acetic acid. It was also observed that minute vessels that contracted from 4 to 3, afterwards became dilated to 6 before congestion and stagnation occur- red. The smaller veins were seen to contract as much as the arteries of the same size. INFLAMMATION. 15^7 walls of the vessel. In the natural circulation of the frog's foot, the yellow corpuscles may be seen rolling forward in the centre of the tube, a clear space being left on each side, which is filled only with liquor sanguinis and a few lymph corpuscles. There are evidently two cur- rents__one at the centre, which is very rapid, and one at the sides (in the lymph spaces, as they are called), much slower. The colored corpuscles are hurried forward in the centre of the vessel, occasionally mixed with Fig. 135. some lymph corpuscles. These latter, however, may frequently be seen clinging to the sides of the vessel, or slowly proceeding a short distance along it in the lymph space, and then again stopping. Occasionally the lymph corpuscles get into the central torrent, whence they are carried off with great velocity, and accompany the yellow corpuscles. It has been said that these corpuscles augment in number, accumulate in the lymph spaces, and obstruct the flow of blood. In young frogs, their number is often very great; but then they constitute a normal part of the blood, Fig. 135. An exact copy of a portion of the web in the foot of a young frog, after a drop of strong alcohol had been placed upon it. The view exhibits a deep-seated artery and vein, somewhat out of focus; the intermediate or capillary plexus running over them, and pigment cells of various sizes scattered over the whole. On the left of the figure, the circulation is still active and natural. About the middle it is more slow, the column of blood is oscillating, and the corpuscles crowded together. On the right, congestion, followed by exudation, has taken place. a, A deep-seated vein, partially out of focus. The current of blood is of a deeper color, and not so rapid as that in the artery. It is running in the opposite direc- tion. The lymph space on each side, filled with slightly yellowish blood plasma, is very apparent, containing a number of colorless corpuscles, clinging to, or slowly moving along, the sides of the vessel. b, A deep-seated artery, out of focus, the rapid current of blood allowing nothing to be perceived but a reddish-yellow broad streak, with lighter spaces at the sides. Opposite c, laceration of capillary vessel has produced an extravasation of blood, which resembles a brownish-red spot. At d, congestion has occurred, and the blood corpuscles are apparently merged into one semitransparent reddish mass, entirely filling the vessels. The spaces of the web, between the capillaries, are rendered thicker and less transparent, partly by the action of the alcohol, partly by the exudation. This latter entirely fills up the spaces, or only coats the vessel. 200 diam. 158 PRINCIPLES OF MEDICINE. and in no way impede the circulation. In old frogs, on the other hand, all these, and subsequent changes, may be observed, without the presence of colorless corpuscles. When the capillaries enlarge, however, the central colored column in the smaller vessels may be seen to enlarge also, and gradually approach the sides of the tube, thus encroaching on the lymph spaces. The slower the motion of the blood, the more the lymph spaces are encroached on, until at length the colored corpuscles come in contact with the sides of the vessel; and are compressed and changed in form. The vessel is at length completely distended with colored corpuscles, the original form of which can no longer be dis- covered, so that the tube appears to be filled with a homogeneous deep crimson fluid. This is congestion. If the morbid processes continue, the vessel may burst, causing haemorrhage, or the liquor sanguinis may trans- ude through its walls, without rupture, into the surrounding texture. This last is exudation. II. Theory of Inflammation.—It is of the utmost importance in pathological inquiries to separate facts from theories. Our facts may be correct, although the conclusions derived from them are wrong. This proposition, however generally admitted, is seldom adhered to in prac- tice ; for, in medical writings and statements, we frequently find fact and hypothesis so mingled together, that it often requires considerable critical and analytical power to separate the one from the other. We are, how- ever, in all cases, insensibly led to theorise—that is, to attempt an ex- planation of the phenomena observed, in order that we may derive from them some general principle for our guidance. Such speculation is always legitimate, so.long as we consider opinions to be mere generalisa- tions of known facts, and are ready to abandon them the moment other facts point them out to be erroneous. The phenomena of inflammation, previously described, may easily be demonstrated—they constitute the fads. Let us now examine how they have been attempted to be ex- plained—in other words, what is the theory. 1. The contraction and dilatation of the capillaries are explicable, by supposing them to be endowed with a power of contractility analogous to that existing in non-voluntary muscles. John Hunter thought they were muscular, from the results of his observations and experiments; and they may be shown by the histologist to consist of a delicate mem- brane, in which permanent nuclei are imbedded. Mr. Lister has recently shown that much of the contractility is dependent on fusiform cells, which have the property of shortening themselves, and which run trans- versely round the vessels. In structure, then, they possess elements closely resembling the muscular fibres of the intestine, and we know that, like them, they may be contracted or dilated by emotions of the mind (that is, through the nerves), or by local applications, that is directly. The narrowing of these tubes, therefore, may be considered, as Cullen thought it was, analogous to spasm ; while their dilatation may be referred either to the relaxation which follows such spasm, or to muscular paralysis. The recent observations of CI. Bernard and others as to the effects produced by dividing the large nervous trunk of the sympathetic in the neck, have singularly confirmed this theory. INFLAMMATION. 150 2. The rapid and slow movement of the blood is explicable on the hydraulic principle, that when a certain quantity of fluid is driven for- ward with a certain force through a pervious tube, and the tube is nar- rowed or widened, while the propelling force remains the same, the fluid must necessarily flow quicker in the first case and slower in the second. It has been supposed, from the throbbing of large vessels leading to con- gested parts, that they pump a larger quantity of blood than usual into them. This was called " determination of blood " by the older patholo- gists, and is now known not to be a cause, but a result, of the changes going on in the capillary vessels and tissues of the affected part. The oscillatory movement, seen later in the transparent parts of small animals, has not been observed in man, and probably depends, in the former, on a weakened power of the heart. 3. It is the stoppage of the blood, and exudation of the liquor san- guinis, however, which is most difficult to explain ; for why, so long as there is no mechanical obstruction (and during this process none has ever been seen), should the circulation through the capillaries of a part cease ? In reasoning on this matter, observation must ultimately satisfy us that it cannot depend upon any mechanical impediment, such as the plugging-up of the vessel by colored corpuscles (Boerhaave) ; multipli- cation of the colorless corpuscles (Addison and Williams); change in the specific gravity or viscidity of the blood in a part (Wharton Jones), or of the corpuscles in particular (Bruecke); obstruction of the venous circulation (G.Robinson); or adhesiveness of the blood corpuscles (Lister.) That the blood corpuscles, indeed, have a tendency to aggregate together is certain; and I have frequently seen what Mr. Lister has described— namely, a roll of them projecting from a side vessel into a larger one, and oscillating in the current without separating. But that this is produced by a viscous condition of these bodies, which causes their surfaces to stick together, as he appears to think, is negatived by the fact, that not unfre- quently I have seen one or more of them approach rapidly a vessel in the inflamed tissue not yet obstructed, then proceed slowly, oscillate for a while, until at length, getting beyond the diseased parts, it has again darted off with the same velocity as it came. Again, it may frequently be observed, when a vessel is so full of colored corpuscles that they can no longer be distinguished, and seem to have melted together, that on rupturing it, these bodies are extravasated, at once assume their original form, and arrange themselves just the same as they do on coming from a healthy structure. I cannot suppose, therefore, that the cause of stasis is connected with adhesiveness of the blood corpuscles; indeed, many of the valuable observations of Mr. Lister himself only confirm what I have long maintained—namely, that they are simply drawn too-ether and brougiit more closely into contact by some external force, which is excited by irritation of the surrounding tissue. The only theory which appears to me capable of explaining the well- recognised changes in inflammation, is one which attributes them to a vital force, not seated in the blood or blood-vessels, but in the tissues out- side the vessels. We have previously seen, when speaking of secretion and nutrition, that a power must exist in the ultimate molecules of the textures, whereby they attract and select materials from the blood. A 160 PRINCIPLES OF MEDICINE. modification of this power, whereby the attractive property is augmented, and the selective one diminished, at least offers us an explanation con- sistent with all known facts, and seems to be the only active agency to which we can ascribe the aggregation of the colored particles to one an- other in the inflamed part, their approach to the vascular wails, and the passage through these last of the exudation. This increased attraction, the result of irritation operating on the nearest blood-vessels, producing in vascular parts exudation, constitutes inflammation. It may cause other effects, which, as we shall subsequently see, ought to be distinguished from that morbid state. The nature and mode of operation of this attrac- tion may be illustrated by the well-known effects which an electrical current produces when passing round a piece of soft iron. Let the chemical action on the metallic plates be regarded as the irritant, the excited electrical stream as the attractive force evolved, then the adhesion of a piece of iron to the one affected by the induced current represents the effects on the blood. So long as this current influences the iron within the helix, the attractive power exists; and so long as a certain amount of irritation operates on the tissue does inflammatory congestion continue. In both cases, also, the increased attractive force so produced must be molecular—that is, must depend upon the altered relations existing among the ultimate molecules of the iron in the one instance, and those of the living tissue in the other. III. The necessity of giving to the word " Inflammation " a de- finite meaning.—On this point Andral has well observed :—" Created in the infancy of science, this expression, altogether metaphorical, was destined to represent a morbid state in which the parts appeared to burn, to be inflamed, etc. Received into general language without any precise idea having ever been attached to it—in the triple relation of symptoms whieh announce it, of the lesions which characterise it, and of its intimate nature—the expression ' inflammation' has become so very vague, its interpretation is so very arbitrary, that it has recently lost its value. It is like an old coin, without an impression, which ought to be removed from circulation, as it only causes error and confusion." Magendie says : " One could fill an entire book with all the ideas which represent the word ' inflammation,' for it i3 synonymous with the word ' disease.' " To judge of the correctness of these statements, let us for a moment attend to what has been called inflammation, and the contradictory ideas which prevail on this matter. 1. Symptoms have been supposed to constitute inflammation, and especially pain, heat, redness, and swelling. Yet the most fatal inflam- mations are now known to represent only one or two of these symptoms, and in not a few no single one of them has been recognised. For ex- ample, an old man may suddenly lose his appetite and strength; his respirations become hurried and feeble; his chest, on examination, is dull on percussion; mucous rattles are heard by the ear, and he dies. On opening his body grey hepatization has attacked the lungs, which are infiltrated with pus. He has from first to last had no pain, there has been no heat, on the contrary, the temperature was diminished; no red- ness nor swelling is anywhere detectable. Such cases have been called INFLAMMATION. 161 latent pneumonia, and latent inflammations of every viscus are very com- mon and very fatal. The truth is, the great writers on the subject have been surgeons, who, because phlegmonous abscesses and external inflam- mations are usually accompanied by these signs, have supposed them to characterise all inflammations. Modern clinical investigation, however, has demonstrated that in the brain, lungs, heart, pleura, kidneys, and internal organs, inflammation frequently presents no such symptoms.* Not only, therefore, are the cardinal symptoms not characteristic of inflammation, but the idea that such is the case has led to the most mis- chievous results in practice. 2. Is irritation of texture inflammation ? This doctrine has long been formularized by the expression, ubi irritatio ibi affluxus. Irritation may, as we have seen, produce inflammation, but very often it does not do so. It may simply excite the nerves, and occasion heat and redness for weeks without causing inflammation. Even when textural irritation is excited through the nerves by reflex action, the vessels immediately in connection with such nerves are not more disturbed than those at some distance, showing that the effect must be produced through the elements of the tissue. When applied at intervals it may produce induration and hypertrophy of texture, as when a corn grows; but this is not inflam- mation. It may produce cell-growth and cell-multiplication in any texture, but this, also, is not inflammation,, as it may be a fibrous tumor or a cancer. We cannot, therefore, characterise inflammation by the cause which occasions it; we must look for something significant in the parts diseased. 3. Is contraction or dilatation of the blood-vessels inflammation ? We see paleness and redness of tissues, in consequence of these alterations in the vessels constantly occurring from mental emotions or exposure to cold and heat, friction, etc.; yet no one would say of a face suffused with a blush, red with anger, or warm from exposure to heat, that it is inflamed. In the experiments of Bernard on the sympathetic nerves, intense redness and excessive heat in parts have been maintained for weeks without inflam- mation. To produce it something evidently must be superadded. Mere congestion, therefore, ought to be carefully separated from inflammation. 4. Is capillary haemorrhage inflammation ? This is a result of con- gestion and rupture of the vessel from over-distension with blood. It often accompanies, but is by no means essential to, inflammations. It may also occur under circumstances where inflammation is not to be thought of—as, for example, in menstruation. This periodical congestion and haemorrhage from the capillaries, though frequently accompanied by all the so-called cardinal symptoms, can never be regarded as in its nature inflammatory. It is not a monthly metritis and ovaritis. Hence capil- lary haemorrhage, like congestion, requires something more to convert it into inflammation. 5. Is serous effusion inflammation ? This constitutes dropsy, and is always dependent on venous congestion. Hence, when important organs—such as the heart, lungs, liver, or kidneys—are so diseased * See case of Edward Campbell (acute pericarditis); of John Young (adherent pericardium); of Peter M'Guine (acute pleurisy); of William Dow (pneumo-thorax), etc. 11 162 PRINCIPLES OF MEDICINE. as to prevent the return of blood from the capillaries, oedema occurs. Mechanical pressure on, or internal obstructions of veins produce the same effect. This is not inflammation. The so-called serum of a blister is, in truth, an exudation, contains fibrin, and coagulates on cooling. It is not allied to the dropsies, but is truly inflammatory. 6. Is stoppage of the blood (stasis) inflammation ? On this point Mr. Norris has recently pointed out* that stoppage of the blood, with aggregation of the corpuscles, may arise—1st, from constriction of .the arteries, and thus shutting off the cardiac force from the capillaries; 2d, from weakening the heart's contractions; and, 3d, in a limb, from strangulation. In neither of these cases is there inflammation. The experiments of Mr. Lister show that carbonic acid, applied locally, pro- duces such congestion, although his employment of the term " inflamma- tory congestion " in such cases, shows that he has not distinguished this condition from true inflammation. In asphyxia, the blood-vessels in the lungs are highly congested and the circulation arrested; but there is no pneumonia. 7. Is the exudation of the liquor sanguinis inflammation ? To this I answer, Yes. It is in truth, the only morbid phenomenon—the only part of the process, which, whenever it occurs, unequivocally charac- terises an inflammation.! The late Dr. Alison maintained, that what was requisite to give precision to the general notion of inflammation was, in addition to the four cardinal symptoms, to include in it a tendency always observed to effusion from the blood-vessels of some new products capable of assuming the form of coagulated lymph or purulent matter. But, as this tendency to a certain act can never be separated from the act itself, or be recognised in the body, it cannot give the precision which is de- sired. Indeed, it is only when the exudation has occurred that we can ever feel satisfied that even the tendency existed. It follows that no one of the preliminary phenomena, nor all of them combined, constitute an inflammation unless exudation has occurred; so that, for all practical as well as scientific purposes, it may be said that this morbid state con- sists essentially of an exudation of the liquor sanguinis.! * Proceedings of the Royal Society, vol. xii., p. 258. f The term exudation has been introduced into pathology, not only to express the act of the liquor sanguinis passing through the walls of the blood-vessels, but also to denominate the coagulation of the fibrinous portion of the liquor sanguinis itself, upon the surface, or in the substance of any tissue or organ of the body. The use of this term removes a difficulty which morbid anatomists have long experienced; and hence it has of late years been extensively used to indicate various kinds of morbid deposits. Thus it has been applied to all those processes hitherto termed inflamma- tory, tubercular, and cancerous; it may be associated with every form of morbid growth; it often gives rise to concretions, and frequently constitutes the soil h which grow those parasitic vegetations or cryptogamic plants of a low type, which communicate essential characters to certain diseases. Under the head of exudatioD, indeed, considered as a morbid process, is comprised the greater part of organic, as distinguished from functional diseases; of lesions of nutrition, as separated from lesions of innervation. X Mr. Norris even argues that exudation precedes the stoppage of the blood, and is the cause of it. This he denominates the primary exudation, which, by causing increased viscidity of the blood, produces what he calls homogeneous stasis. INFLAMMATION. 163 The objections to this view are of two kinds. In the first place, it is said that epithelium, cartilage, cornea, and non-vascular parts, may be inflamed, although they contain no blood-vessels, and consequently can have no exudation poured into them. But the morbid changes which occur on irritating these structures are so widely different from those which are produced in vascular parts that they ought never to be con- founded together. Thus, on irritating non-vascular structure, such as cartilage, we find the cells nearest the injury enlarge, the included con- tents gradually form secondary cells, and the intercellular substance be- comes opaque and soft from deposition of molecules, or from fibrillation. The first of these changes—namely, enlargement of pre-existing cells—is well shown in a section of the patella into which an incision was made by Redfern (Fig. 136); and the second, or molecular deposition and fibrillation, in Fig. 137. The same occurs in epithelium and cornea 164 PRINCIPLES OF MEDICINE, matous inflammation, sometimes include under it fatty degeneration of , muscle, sometimes hypertrophy of texture, and sometimes even cancer. According to such views, the term inflammation would equally well apply to an encephaloma as to the pulpy softening of cartilages—to a corn as to a fibro-nucleated growth. We argue it should be applied to none of these, but ouly to that perverted alteration of the vascular tissues which produces an exudation of the liquor sanguinis. Should different results be occasioned by irritation, they are congestion on the one hand, or in- creased growth—that is hypertrophy—on the other. In the second place, it is now known that exudations occur, and are often very fatal, under circumstances where the old idea of inflammation, or an active condition attended by acute symptoms, cannot apply. In short, the modern pathologist and the senior practitioner are widely divided in thought. The former regards the essence of the process; the latter the occasional phenomena it presents. As there is no necessary relation between the two, it follows that the only escape from the con- fusion thus arising is, as Andral suggested, the removal of the word inflammation from medical nomenclature. No doubt the future employ- ment of the terms congestion, stasis, exudation, morbid growth, etc. etc., would remove much of our difficulties. Those, however, who continue to use the term inflammation can only do so with exactitude in the sense of an exudation of the liquor sanguinis. This is the only view of it which is consistent with all known facts, and it possesses the further merit of having led in recent times to the most valuable results in practice. Terminations of Inflammation. Once established, further changes occur in the exuded matter. These have been called the terminations of inflammation, and were considered by John Hunter to be adhesive, suppurative, ulcerative, gangrenous, etc. I have long taught, however, that we should distinguish two great results of the exudation—viz., that it may live or die. If the exudation lives, it constitutes a molecular blastema, in which new growths, temporary or permanent, spring up according to the molecular law of development, such as pus and adhesive lymph. When, on the other hand, the exudation dies, three things may result—1st, Rapid death, with chemical decom- position, producing mortification or moist gangrene; 2d, Slow death, with disintegration of tissues, causing ulceration; 3d, What may be called a natural death of the transformed exudation, whereby it is broken down, liquefied, and at length absorbed. This is resolution. IV. Vital Transformations of the Exudation.—We find that the peculiar constitution of the blood, or the general vital power of the organism, exercises a very powerful influence on the development of the exudation. This has been long recognised by pathologists in certain conditions, denominated respectively diathesis, dyscrasia, or cachexia. I propose at present to direct your attention to some of the changes which take place in the exudation as it occurs in the body during health. These vary—1st, As it occurs on serous membranes, where it exhibits a finely fibrous structure, and has a strong tendency to be devoloped into INFLAMMATION. 165 molecular fibres; 2d, As it occurs on mucous membranes, or in areolar tissue, where it is generally converted into pus corpuscles; 3d, When it occurs in dense parenchymatous organs, such as the brain, where it assumes a granular form, and is associated with numerous granular sorpuscles; 4th, As it is poured out after wounds or injuries, and occurs on granulating sores. In this last case the superficial portion is trans- formed into pus corpuscles, while the deeper seated is converted, by means of nuclei and cells, into nucleus and cell fibres, which ultimately form the cicatrix. 1. On examining the minute structure of the exudation on a serous surface when recently formed, and when it presents a gelatinous semi- transparent appearance, it will be found to be made up of minute filaments mingled with corpuscles (Fig. 138). The filaments are not the result of the development of either a nucleus or a cell, but are formed by the simple precipitation of molecules, which arrange themselves in a linear manner, in the same way as they may be seen to form in the buffy coat of the blood. As the exudation becomes *(&'($Wi firm, the filaments appear more distinct *jf^-^y' and consolidated, varying from j-j-^jtli to ^ I Too oo*Q of" an meQ iQ diameter. Bundles, or different layers of them, often cross each other; and as the lymph becomes older they assume more and more the character of those in dense fibrous tissue. The corpuscles, when newly formed, are delicate and transparent, but in a short time become more distinct, and are then seen to be composed of a distinct cell-wall, enclosing from three to eight granules. They vary in size from T1\^th to Tfo 7th, and the enclosed granules from TI{ntli to To!roota °^an ^nca *n diameter. On the ad- dition of water and acetic acid, the corpuscles undergo no change, al- though sometimes the latter re-agent causes the cell wall to contract and thicken; and at others, to be somewhat more transparent. In 1842, I Fig. 138. rft \®. piillftEj * ft I ■J Fig. 139. Fig. 140. Fig. 142. Fig. 143 separated these bodies from pus cells, and called them plastic corpuscles, from the frequency of their occurrence in plastic lymph. Lebert in 138. Molecular fibres and plastic corpuscles, in simple exudation on a serous a, The latter after the addition of acetic acid. 250 diam. 139. A portion of recent lymph from the pleura. 140. Another portion of the same, further developed. 141. Portion of firm pleural adhesion. 142. Another portion of the same, further developed. 143. The last acted on by acetic acid.—(Drummond.) 180 diam. Fig. surface. Fig. Fig. Fig. Fig. Fig. 166 PRINCIPLES OF MEDICINE. 1845, confirmed my description, and called them pyoid, from their re- semblance to pus. These corpuscles after a time melt away among the fibres, but several of them remain, constituting, as shown by Dr. Drummond, permanent nuclei. After a time, blood-vessels grow in the exuded lymph (see Vascular Growths), the surface of which becomes villous. Into the villi loops of vessels penetrate, and by these the fluid, contained in the interior of shut sacs, is absorbed. The fluid thus gradually diminishes, and when the villous surfaces are brought into contact, they unite, and ulti- mately form the dense chronic adhesions so common between serous membranes. (See pp. 174-75.) 2. Exudation poured out on a mucous membrane sometimes presents a fibrous mass, as in cases of croup and diphtheritis, but more generally it passes into an opaque, unctuous, straw-colored fluid, long known under the name of pus. When poured into the meshes of areolar tissue, and occasionally into the substance of the brain, the same transformation occurs, and then forms an abscess. On examining the minute structure of pus, it is seen to be composed of numerous corpuscles floating in a clear fluid. These corpuscles are globular in form, and vary in size from the goV ota to *^e 12V otQ 0I" an incn m diameter. Their surface is finely punctated. They have a regular well-defined edge, and roll ^..--~s -~, freely in the liquor puris upon each other. v5ft/ $P,. ^i® On the addition of water, they become much (\< <*>, f*X 5§ ^ftlf^-.'o^ increased in size and more transparent, their ^^^feb ^'Wy:> finely punctated surface disappearing. Weak 'J§P'^ K0 acetic acid partially, and the strong acid com- Fisr. 144. Fig. 145. pletely, dissolves the cell-wall, and brings into view an included body, generally composed of two or three granules close together, and rarely four or five, each with a central shadowed spot. These are usually about the coVo^ oi" an inch in diameter. (Figs. 144, 145; also Figs. 66, 67.) In some cases the pus corpuscles now described are surrounded by an albuminous layer closely resembling a delicate cell-wall (Fig. 68), which I first described in 1847. It is about the ToVot'1 or gootn °^an inch in diameter, and is highly elastic, assuming different shapes, ac- cording to the degree and direction of the pressure to which it is sub- jected. Water and acetic acid cause it at once to dissolve, whilst the included pus corpuscles exhibit the usual body .•-■■, __ .,., .., composed of two or three granules. : /If-#'' *' puscles, instead of being round and rolling fi'M^p'^) .O »4Q freely on each other, are misshapen and irre- s-ft ^ ft-* """ gular (Fig. 69), and, on the addition of acetic Fig. 146. Fig 147. acid, the granular nuclei are found to be ill formed or absent (Figs. 146, 147). 8. In parenchymatous organs, the exudation insinuates itself among Fig. 144. Pus cells. Four cells have been acted on by acetic acid. Fig. 145. Pus cells containing fatty molecules, after adding acetic acid. 250 di Fig. 146. Scrofulous pus cells after the addition of acetic acid. Fig. 147. The same. In both specimens the nuclei are irregular or absent. INFLAMMATION. 167 The Fig. 149 the elementary tissues of which they are composed, so that, when it coagulates, these are imprisoned in a solid plasma, like stones in the mortar of a rough cast wall; thus constituting a firm mass, and giving increased density to certain organs. This is well observed in the lung, where, however, a raucous surface extensively prevails, and where the exudation is commonly transformed into pus. In the brain, spinal cord, and placenta, we find the exudation deposited in the form of minute molecules and granules, which are frequently seen coating the vessels externally, and filling up the intervascular spaces (Fig. 148). granules vary in size from the yo^o-th to the j oVo-tii of an inch in diameter. They always contain among them round transpa rent globules, varying in size from the sflVo*!1 *° "au'oo^1 0I> an inck m diameter. These are the nuclei of round or oval cells which may frequently be observed in various stages of development. When fully formed, the cells vary greatly in size, for the most part measuring from the -jftootl1 to T}jth of an inch in diameter. They sometimes con- tain a few oil granules only, at others they are so completely filled with them as to assume a brownish-black appear- ance. Water and acetic acid cause no change in them, although the latter re-agent, on some occasions, renders the cell-walls Imore transparent. They are readily soluble in 'aether, and break down into a molecular mass on the addition of potash and ammonia. These are •granule cells (149). Masses of these granules V^-' may be occasionally seen floating about, of irreg- ular shape, without any cell-wall. They are pro- duced either by the solution of the cell-wall in ^' ^§P» which they are contained, or from the separation, !«• or peeling off, of such masses from the external wall of the vessels; and form granular masses (Fig. 149 a). Pressure causes these granules to coalesce, or the oil to be forced through the cell-wall Occasionally also the cell-wall is ruptured. The granules, masses, and cells just described are found in the colostrum secreted by the mammary glands; in the exudative softenin* of parenchymatous organs; on the surface of granulations and pyrogenic membranes; in the pus of chronic abscesses ; combined with cancerous tubercular, and all other forms of exudation; in the tubes of the kidney when affected with Bright's disease; and in the contents of encysted tumors. In fact, there is no form of cell-growth, whether healthy or morbid, that may not, under certain conditions, accumulate oil or fatty granules in its interior, become a compound granular corpuscle, and thus be rendered abortive. The granule cells in an exudation, however, are the results of a vital transformation of that exudation, and not of mere tatty degeneration of the vessels, as some have supposed. In some Fig Fi- 148. Granular exudation and granular masses, from cerebral softening 149. Granular cells and masses from cerebral softening. 50 di. 168 PRINCIPLES OF MEDICINE. instances I have seen them in all stages of development coating the blood- vessels, as in Fig. 150. That softening from the formation of granules and granular cells may occasionally disappear, and the new structures be absorbed is rendered probable by the history of several well-recorded cases; but the changes there- by produced, especially in nervous textures, have not hitherto been made the subject of special in- vestigation. 4. If a recently-formed granulation on the surface of a healing sore be examined, numerous cells will be observed, of various shapes, and in different stages of development. Some are round, others caudate, spindle-shaped, elongated or split- ting into fibres, as originally described by Schwann (Fig. 151). In many cases there may be seen a number of free nuclei, imbedded in a slightly fibrous blastema, elongated at both ends, becoming fusiform, and splitting up the surrounding exuda- tion, as described by Henle. Not unfrequently the nuclei may be seen developing themselves into elastic fibres, in the same exudation which contains cells that are passing into white fibres. Indeed, the process of cicatriza- tion in its various stages and in different tissues, offers the best means of studying the manner in which nucleus and cell fibres are respectively formed. As these _ .■-, ^-v (-) .■) \s ' %m fibres are developed in the deeper layers of the exudation, a villous vascular basis is formed, and the superficial pus- corpuscles, after having served to protect the more permanent growths are thrown off in the form of dis- charge. When the fibrous structure becomes more con- sistent and dense, the amount of pus diminishes, and a greater tendency is manifested by the exudation to pass into permanent tissue.. At length pus ceases to be developed ; the whole remaining exudation is transformed Fig. 150. Two vessels coated with exudation from softening of the spinal cord. Granular cells may be seen forming in it. 250 diam. Fig. 151. Vertical section of a granulating sore. Externally, pus corpuscles, deeper, fibre cells in various stages of development into fibre. The looped blood- vessels are seen enlarged at their extremities, magnified 100 diameters linear. On the left the cells are magnified 250 diameters linear. INFLAMMATION. 169 into fibres; a new surface is produced, which after a time contracts and forms the permanent cicatrix. V.—Death of the Exudation.—The exudation may die in three ways—1st, Instead of passing through the vital transformations we have previously described, it may die rapidly—constituting what has been called Mortification or Moist Gangrene; 2d, It may die slowly—causing gradual disintegration and loss of texture, and thereby forming what has been denominated ulceration ; 3d, There is a natural death of the exudation, which is resolution. Mortification or Moist Gangrene. Occasionally a very large amount of blood-plasma is thrown out; a greater or smaller number of capillaries are also ruptured, and blood cor- puscles more or less mixed up with the liquor sanguinis exuded. The exudation thus formed compresses the part into which it is thrown out, paralyses the nerves, obstructs the blood-vessels, and arrests the circula- tion in them. Under these circumstances, instead of forming a blastema for the production of new structures, it undergoes chemical changes, whereby decomposition is induced, and then the part is said to be morti- fied, or to be affected with moist gangrene. This change commences first in the blood extravasated, which becomes of a purple color more or less deep; the corpuscles break down and become disintegrated; their haematozine dissolves and colors the serum; and, should the exudation have coagulated, it forms brown, rust-colored, purple, or blackish masses. An acid matter is now formed, which, acting on the neighboring tissues, produces foetid gases, that are abundantly given off from the affected part. Sulphuretted hydrogen is evolved, which causes the blackish sloughs usually observed in such cases, and discolors silver probes and the pre- parations of lead. After a time, the elementary tissues surrounding or involved in the exudation, become more or less affected. The tranverse stria? in the fasciculi of voluntary muscles first become pale, and are then obliterated. Cellular tissue, fat, and other soft substances lose their con- nection, and fall into an undefined granular mass. The tendons and fibrous tissues retain their characteristic structure for a long time after the other soft parts have been reduced to a softened pulp. The bones resist the action longest, but at length, commencing externally, they become rough, soft, and are more and more broken down, and reduced to the same pulpy consistence and granular structure as the surrounding parts. As the tissues thus become broken down, and fluid, they are dis- charged from the system in the form of an ichorous matter, which, examined microscopically, presents numerous granules, imperfect or broken-down cells, blood corpuscles, and fragments of filamentous tissue or of the other structures involved. If the morbid action be seated in the subcutaneous tissue, the skin soon becomes affected; and an opening is formed, which rapidly enlarges, and gives vent to the discharge. In a similar manner, gangrene of internal organs, by destroying the inter- mediate parts, at length enables the fluid to reach the surface, or to find its way into the excretory passages, such as the bronchi, the intestinal canal. the meatus auditorius, etc. In this manner, life may be endangered, by 170 PRINCIPLES OF MEDICINE. the destruction of organs necessary for its continuance; by the exhaustion resulting from the discharge; and sometimes by the absorption of the ichor- ous matter, which, entering the circulation,acts as a poison to the economy. On the other hand, a favorable termination may take place, either by the dead substance breaking down, and bein gevacuated externally, or by its being separated en masse in the form of slough. In such case a process of regeneration and healing may be set up in the exposed living texture, which may produce a cicatrix, in the manner formerly Spoken of. It may be asked whether mortification is the result merely of a greater amount of the exudation ? or, whether it is dependent besides on other circumstances, such as a peculiar state of the atmosphere, which favors the decomposition of the exudation poured out ? In order to answer these questions, we must distinguish between ordinary mortifica- tion arising from a variety of circumstances, and moist gangrene properly so called, which is undoubtedly the rarest of all the terminations of ex- udation. Mortification may be produced by the application of chemical or mechanical agents, which directly destroy the tissues. It also often arises through severe and complicated injuries, in which arteries leading to the portions of structure affected have been divided or crushed. In old persons, it follows obstruction in the blood-vessels, or is dependent on circumstances not yet ascertained. In none of these cases is it a result of inflammation. But when stasis of the capillaries is produced to a con- siderable extent, followed by the exudation of a large quantity of blood- plasma, which, instead of passing into organization, undergoes the changes previously described, then moist gangrene, properly so called, is produced. We see this take place after burns, after long exposure to frost, and in certain cases of erysipelas. Here the amount of exudation is considerable, the pressure caused by it extreme, the obstruction to the circulation in the neighboring parts correspondingly great; so that these, as well as the exudation itself, is destroyed. In this sense, therefore, it may be said to depend on the rapidity and amount of the exudation ; but not in the sense of those who consider adhesion, suppuration, and gangrene, as different stages of one process. Suppuration, as we now know, has no connection with adhesion; it is opposed to it; nor is it in any way related to mortification, which must be considered as a primary altera- tion of the exudation. In mortification the vitality of the exudation is lost, and instead of passing into organization, it becomes subject to the chemical laws of dead matter, and undergoes putrefaction. Fig. 152. Moist gangrene, following compound fracture—all the injured parts in- filtrated with exudation, which has died and mortified.—Liston. INFLAMMATION. l < * Now in order that organic substances may enter rapidly into putre- faction, it is necessary that they find sufficient oxygen and water for all their carbon to be transformed into carbonic acid, all their hydrogen into water, and all their azote into ammonia. When these conditions are not completely fulfilled, transition or intermediate substances are formed. Fig. 153. If there is not sufficient oxygen, for instance, an excess of carbon is pro- duced in the debris. There is also often developed a species of destruc- tion by contact, which causes parts undergoing decomposition to excite it in neighboring ones (eremacausis of Liebig); which does not take place in dry gangrene. A gangrenous stomatitis (Cancrum oris) will thus destroy, in a short time, a large portion of the soft parts of the lips and face, and Noma the genitals of young female children. This appears to depend upon the quantity of destructive fluid or mixture generated in the process. On the other hand, several weeks may occur before a dry gangrenous foot is completely separated by decomposition. There are sometimes external causes also which seem to produce mor- tification, independent of the amount of exudation, or the rapidity with which it is thrown out. During the summer of 1836, I watched with great care the progress of sloughing gangrene, prevalent, not only in the Infirmary of Edinburgh, but throughout the city generally. All kinds of sores and wounds were affected by it, even those of a specific nature, such as chancres, etc. Neither youth nor age was exempted from it. It affected not only those who were debilitated from disease, through intemperance or bad diet, but those also apparently in the most robust health. Thus a servant girl, aged 16, who had never suffered from ill- ness, and was of a robust constitution, fell down upon some glass bottles, \ and slightly cut her left thumb. A week after, she entered the Infirmary with an ulcer the size of a shilling, filled with a brownish-black slough, discharging a foetid and sanguineous fluid. In this, as well as other cases which occurred, it became impossible to attribute the gangrene to the violence of the injury, the amount of exudation, a state of cachexia, or indeed to any circumstances connected with the individual. It could not arise from contagion, as it originated simultaneously in different parts of the city, in individuals who had no communication with each other, and was not confined to the Infirmary, where the system of dressing wounds precluded the possibility of such an occurrence. We are, there- fore, compelled to ascribe the cause to something in the atmosphere. Most writers have noticed the connection between a certain state of the atmosphere and the prevalence of hospital gangrene and of dysentery, Fig. 153. Dry gangrene from debility—being death of the pre-existing tissues, uncom\?cted with exudation.—Lislon. 172 PRINCIPLES OF MEDICINE. as well as their more frequent occurrence in summer and autumn—that is, at a period of the year when increased temperature favors the de- composition of animal matter. The good effects which result from change of air, when every kind of treatment fails, still further point out its con- nection with some atmospheric changes. These may probably depend upon some peculiar electrical state, not yet explained, powerfully influenc- ing the chemical combinations of the diseased part, and preventing cell- growth. At least such is what we may reasonably suppose, from all the facts with which we are acquainted on this head. The disease is similar to blight among vegetables, or the potato-disease. Ulceration. The process of ulceration is somewhat similar to that of mortification, but is more chronic in its progress; the exudation, instead of undergoing decomposition, exhibits an indisposition to pass into cell-formation. In this case the exudation is poured out slowly, it coagulates and presses upon the surrounding parts, more or less obstructing the flow of blood to them and acts as a foreign body. By means of the continued pressure, the circulation is obstructed, and death of the portion affected results. This dead portion is sometimes imprisoned in fresh exudation, as the ulceration extends, and the whole part affected at length becomes disin- tegrated. All this time the exudation exhibits little of that tendency, so conspicuous in healthy persons, to undergo changes in itself, and when examined microscopically, is found to consist principally of very minute granules. These are occasionally mixed with irregularly-formed cells, usually more or less angular, containing one or more granules. The cells are more numerous in proportion to the stage of the ulceration, and the healthy powers of the constitution. The different granules and imperfect cells, with the structures they involve, at length become broken down and separated from each other, constituting a semi-fluid mass, which has a tendency to point where it can most readily be dis- charged, that is, towards the surface of the skin or mucous membranes. Here, on account of the less degree of resistance offered, the continued pressure and disintegration of tissue first causes an aperture to be formed. Another portion of solid exudation is now broken down, with the tissues involved in it, and in this way the opening is enlarged. If the morbid process continue, a fresh exudation is slowly poured out below the already coagulated blood-plasma, which supplies the loss thrown off in the form of discharge, and thus chronic ulcers may be continued in- definitely. The whole of this process may be well observed in scrofulous and syphilitic ulcers, or in the callous sores of the legs in weavers and others of a cachectic constitution. Indeed the general powers of the constitution are almost always in such casef enfeebled, and hence the indisposition of the exudation to be transformed into cells. Ulcers produced by direct pressure are occasioned in a similar manner; only in such cases the pressure is not derived in the first instance from the solid exudation poured out. Thus, in stumps not sufficiently covered by soft parts, in places long pressed upon by lying, or by the growth of tumors, the vitality of the part is slowly destroyed. INFLAMMATION. 173 At the same time an exudation is poured out from the neighboring vessels, which becomes broken up, and assists in disintegrating the textures whose vitality is destroyed. The finely molecular particles are thus absorbed, whilst the grosser portions are thrown off in the form of discharge. All ulcerated surfaces are covered with a fluid, which varies in character according to the nature of the sore. Healthy granulations are covered with laudable purulent matter, the corpuscles in it presenting their normal character. In chronic, scrofulous, and syphilitic sores, the corpuscles are generally of an irregular form, constituting what has been denominated unhealthy purulent matter. Not unfrequently the ulcer is covered with a discharge, either of a thin dirty yellowish tint, or more or less sanguinolent and foetid. In the latter case the discharge has received the name of sanies, and is similar in character and constitution to that observed in the fluid accompanying moist gangrene—that is to say, there are in it traces of imperfect cell-formation mixed with numerous molecules, and the shreds or debris of the structures involved. Ulceration has by most writers since the time of Hunter been re- garded as the result of a peculiar operation, which he denominated ulcerative absorption. No doubt the process, such as we have described it, is peculiarly favorable to the production of a fluid containing mole- cules so minute that they may readily permeate the neighboring vessels by endosmosis. But it must not be overlooked that much of the sub- stance lost in ulceration, especially of the more consistent and tough structures, after having been more or less broken up, is thrown off from the surface in the form of discharge. This is proved by direct observa- tion. In either case all such parts first lose their vitality, from the pressure to which they are subjected, and then, being disintegrated,, the fluid and finer parts may be absorbed, whilst the coarser are thrown off from the surface. In bones the processes corresponding to mortification and ulceration in soft parts, are generally denominated Necrosis and Caries. Resolution. When pus is not evacuated externally, the cells ultimately dissolve, their walls disappear, the included nuclei and granules separate, and are converted into a fluid. This passes into the blood, increases for a time its effete constituents, but is at length excreted by the emunctories. Mean- while the original abscess,, or collection of matter, is said to be resolved. Numerous observations have satisfied me that this is the process which a pneumonia undergoes on its removal. In this disease the exuda- tion is infiltrated into the air vesicles and minute bronchi, and between the fibres, blood-vessels, afid nerves of the parenchyma, imprisoning the whole in a soft mass, which coagulates and renders the spongy texture of the lung more dense and heavy, or what is called hepatized. This accomplished, no air can enter, the nerves are compressed, the circulation is in great part arrested; and the object of nature is now to convert the solid exudation once again into a fluid, whereby it can be partly evacuated from the bronchi, but principally reabsorbed into the blood, and excreted 174 » PRINCIPLES OF MEDICINE. from the economy. This is accomplished by cell-growth. In the amorphous coagulated exudation, granules are formed; around groups of these cell-walls are produced, and gradually the solid amorphous mass is converted into a fluid crowded with cells. This is pus. The cells, after Fig. 154. passing through their natural life, die and break down, and thereby the exudation is again reduced to a condition susceptible of absorption through the vascular walls, and once more mingles with the blood, but in an altered chemical condition. In the blood the changed exudation (now called fibrin) undergoes further chemical metamorphoses, whereby, according to Liebig, it is converted by means of oxygen into urate of ammonia, choleic acid, sulphur, phosphorus, and phosphate of lime. The urate of ammonia, by the further action of oxygen, is converted into urea and carbonic acid; the choleic acid into carbonic acid and carbonate of ammonia; the sulphur and phosphorus into sulphuric and phosphoric acids, which, combining with an alkali or earth form sulphates and phosphates. If it should happen that the quantity of oxygen taken is not sufficient completely to accomplish this cycle of changes, then, instead of urea, either urate of Ammonia appears in the urine, or if the ammonia have entered into any other combinations, pure crystals of uric acid. In consequence of these or similar changes, the exudation is finally removed from the economy. The same process takes place in abscesses, and is frequently seen in buboes, which instead of being opened become harder and harder, smaller and smaller, until at length they disappear. In a pleurisy or pericarditis, the transformations occurring in the exudation are different. We have previously described the changes which follow pleurisy (pp. 165-66). Let us now follow them in the case of peri- carditis. When a severe inflammation of the pericardium occurs., the liquor sanguinis is exuded in considerable quantity, separating the serous layers to a greater or less extent. After a time the fibrin coagulates and forms a layer which attaches itself to the membrane, whilst the serum of the blood accumulates in the centre. The coagulated fibrin at first assumes t the form of molecular fibres, plastic or pyoid dells are formed in it (Fig. 138), others throw out prolongations, so as by their union to form a plexus, which, communicating with the vessels below the serous mem- Fig. 154. Three air vesicles of a pneumonic lung, filled with exudation in different stages of development, a, Molecular exudation recently poured out; b, Cells form- ing in the exudation; c, Cells (pus-cells) fully formed. See case of Alexander Walker >among Diseases of the Nervous System. 250 diam. INFLAMMATION. 175 brane, renders the exudation vascular (Fig. 254). Gradually the surface assumes the appear- ance of a villous membrane (Fig. 155), which possesses also the absorbent fuuctions of one. The enlarged villi frequently contain vacuoles or spaces, reminding me strong- ly of the general structure of the pla- cental tufts, than which nothing can be imagined more perfectly adapted for the purposes of ab- sorption (Fig. 156). In consequence, the serum now disap- pears, the two false membranes are brought into contact, and thus the absorption, as soon as Fig. 156. Fig. 155. Layers of lymph in pericarditis, presenting the form of large villi.— (Cruveilhier.)—Half the real size. Fig. 156. Structure of the villi in pericarditis. On the left of the figure are some villi treated with acetic acid, and thereby rendered very transparent, showing the elongated nuclei of the fibre cells of which they are principally composed, a, The vacuoles or spaces common in these villi; b, Group of epithelial cells which in many places covered the villi; c, Cells of various shapes, easily squeezed from the soft vil- lous structure, undergoing the fibrous and vascular transformations.—(See Fig. 254.) 200 diam. Fig. 155. 176 PRINCIPLES OF MEDICINE. it is no longer required, is put an end to, and adhesion occurs. The matters absorbed into the blood pass through the same series of changes as those in pneumonia do, and are eliminated from the economy in a similar manner. Such is the natural progress of pericarditis. The two kinds of processes now described exhibit the same wise de- sign in pathological as we everywhere find in physiological actions. In the vascular tissue of the lung, new blood-vessels are'unnecessary. But in the non-vascular serous membrane, they must be formed to bring about removal of the morbid products. In the one case the entire exudation is transformed into cells to produce rapid disintegration and absorption, which latter is easily accomplished by the already formed numerous vessels of the lung. In the other case the exuded liquor sanguinis is separated into solid and fluid parts, and as there are no vessels in the serous membrane, they are formed in one portion of the exudation to cause absorption of the other. VI. General Treatment of Inflammation.—The foregoing facts and considerations must lead us to the conclusion, that practically the medical man may be called upon—1st, To check or diminish the inflam- matory congestion; 2d, When exudation has coagulated, to further its removal from the economy; or, 3d, If this cannot be accomplished, to render its products as little injurious to the system as possible. In each case, we can only proceed correctly by knowing the manner in which nature operates, and assisting those curative changes which she invariably attempts to bring about. We have seen that exudation follows certain preliminary alterations in the capillary vessels, and is immediately dependent on relaxation or paralysis of their coats, and transudation through them of the liquor sanguinis. Once formed, it passes through certain changes or developments, which vary according to the nature of the texture in which it occurs, its amount, the rapidity with which it is formed, and its inherent constitution. The exudation, by means of these changes, is rendered soft, is more' or less disintegrated, and is absorbed into the blood to be excreted from the economy. A correct treatment, therefore, will be influenced by the stage and nature of the inflamma- tion. 1. To check or diminish the inflammatory congestion, we must adopt measures to restore the capillaries to their normal condition, prevent their distension with blood, and lessen the attractive power (whatever that is) which draws the blood into the irritated textures. This is ac- complished—1st, By local applications of cold and astringents, which stimulate the capillaries to contraction; 2d, By soothing topical applica- tions, such as warm fomentations, opiates, etc., which relieve the irrita- tion of the nerves in the part. " Blood-letting, local or general, has long been supposed capable of meeting this indication, but theoretically it can no longer be defended, and practically the use of the former has of late years been confined to some active congestion of the external tissues, while that of the latter has been abandoned. 2. When the exudation has coagulated, it constitutes a foreign body, which either becomes organised, or is removed by its dying. In the one case it acts as a blastema, in which cells are developed that ultimately INFLAMMATION. 177 break down, and so render it capable of being absorbed (resolution), or they are converted into a tissue that becomes permanent. In the other case it disintegrates slowly, constituting ulceration—or putrefies, formiug moist gangrene, when it is separated from the economy in discharge or as a slouch. It is by regulating the formative power of the exudation that we check or favor resolution; and we can only do this by employ- ing those means which lessen or advance cell-growth in all living organ- isms. Thus locally, cold, dryness, and pressure check—while heat, moisture, and room for expansion favor—growth. And as regards the general system, the increase or diminution of food, nutrients and stimuli, act for or against this object. With a view of diminishing the general excitement that prevails, tartar emetic has been recommended, and to assist the absorption of the exuded matter, calomel has been a favorite remedy; but the manner in which these act has been disputed, and whether it be as a solvent of the effete matters in the blood, or by operating on the excretions, is yet un- determined. The former probably acts in both these ways—the use of the latter, as an antiphlogistic, has of late years been almost abandoned. The action of counter-irritants, although undoubtedly useful in removing pain and in causing absorption of chronic exudations, is little understood, and belongs to the most mysterious department of therapeutics. 3. In order to favor the excretion of the effete matters in the blood, purgatives, diaphoretics, and diuretics, alone or combined, will occa- sionally be found very useful. The influence of these remedies, indeed1, is not confined merely to removing matters which have been absorbed as the result of the secondary digestion ; but, by their depurating qualities, they favor indirectly the rapid absorption of the exudation. Formerly it was supposed that the essential phenomenon of inflam- mation consisted of the alteration in the blood and blood-vessels. The views previously detailed seek to establish that this process really con- sists in irritation of the extra-vascular elements of the textures, pro- ducing exudation of the liquor sanguinis. The former doctrine naturally led its upholders to maintain an antiphlogistic treatment; the latter one as naturally led to an opposite practice. There is no inflammation so well capable of testing the value of any particular treatment as a pneu- monia : first, because there is none that can be more accurately deter- mined by functional symptoms and physical signs; secondly, because the perturbation of the system and importance of the organs involved have ever, and must always, attract strongly the attention of medical men; thirdly, because it, perhaps more than any other, has been sup- posed to be amenable to blood-letting and antiphlogistics. It is now eighteen years since a careful investigation into the pathology of inflam- mation induced me to doubt the value of the then universal practice in these cases, and this for the following reasons :— In the first place, the cause of the inflammation is an irritation of the textures—of the ultimate molecules of the part—in consequence of which their vital power of selection is destroyed, and that of their attrac- tion is increased. The removal of blood by venesection cannot alter this state of matters—neither can other lowering remedies. If the inflamma- tion be superficial and limited, local bleeding may relieve the congestion, 12 178 PRINCIPLES OF MEDICINE. as in conjunctivitis, but if exudation has occurred it cannot remove that. In the second place, an exudation or true inflammation having oc- curred, it can only be absorbed by undergoing cell-transformation. Now, this demands vital force or strength, and is arrested by weakness. Hence inflammations in healthy men rapidly go through their natural course: in weak persons this is delayed ; hence their fatality. In the third place, the strong pulse, fever, and increased flow of blood in the neighborhood of inflamed parts, have been wrongly inter- preted by practitioners. They are the results, and not the causes, of inflammation, and show that the economy is actively at work repairing the injury. So far, therefore, from being interfered with and interrupted, they should be encouraged—locally by warmth, which also relieves pain, and internally by nutrients. It follows, fourthly, that if these views be correct, our object in the treatment of internal inflammation should be directed towards bringing the disease to a favorable conclusion, by supporting rather than diminish- ing the vital strength of the economy, and this not by over-stimulating, as was done by Dr. Todd, but simply by attending to all those circum- stances which restore the nutritive processes to a healthy condition. Having been guided by these views in my practice for the last six- teen years, and having seen that gradually they have been adopted by the profession, it is, I think, in my power to offer you the most convinc- ing proof of their correctness, by contrasting the results of an antiphlo- gistic treatment, as formerly practised in pneumonia, with those furnished by the cases that have been carefully recorded by my various clinical clerks in the Koyal Infirmary. For the details, I must, in order to prevent repetition, refer you to section III., in which, under the head of " the diminished employment of blood-letting, etc.," the facts and arguments on this subject are fully detailed. The cases also are given under the head of Pneumonia. All that need be said here is, that the mortality of this disease, which used to exist in large hospitals, varying from 1 in 3 to 1 in 7 cases, is in my wards of the Boyal Infirmary almost nil. Cases of simple pneumonia, single or double, always recover; while the few cases that die owe their fatality to severe complications. From these facts I conclude—1st, That simple pneumonia, if treated so as to support instead of lower the nutritive processes, so far from being a fatal disease, almost invariably recovers. 2d, That the cause of mortality in these cases is exhaustion, either before they come under medical supervision, or, as formerly practised, from an antiphlogistic or a lowering treatment. All bleedings that do not exhaust must be regarded as palliative, rather than as curative. 3d, That the same rule applies to all inflammations, the amount of danger being in direct ratio to the weakness of the system and the exist- ence of complications in the disease, especially blood-poisoning. I need not dwell at length on what it appears to me are these im- portant results. I shall only remark, in conclusion, that, in my opinion, they are not the effect of chance; of empirical experiment; of a change in the nature of inflammation, or of the force of the pulse' in man and TUBERCULOSIS. 179 animals; of an alteration in diet or of drink, or of nervous susceptibility; nor of a change in the type of disease; all of which have been supposed by some to be explanatory of facts which can no longer be denied. The more I consider this subject, the more am I convinced that it is to the advance of medical science only that it can be rightly attributed, and that it is our highest privilege and honor so to consider it. Indeed, no stronger proof can be offered of the improvement in practice that has resulted from a more correct pathology, than the diminished mortality and great success which, it has been shown, now attend our treatment of acute inflammations. TUBERCULOSIS. I propose iu this place to speak of that very common and important morbid condition denominated Struma, Scrofula, and, in recent times, Tuberculosis—that is to say, the formation of Tubercle. The term " tubercle" literally implies a little swelling, and in that sense still serves to distinguish a class of skin disease, under the name of " tubercuke." Its unfortunate application to the rounded and other masses so frequently found in the lungs, bones, and other textures, renders it imperative upon us to define what we now understand by it. At present, therefore, tubercle may be regarded as an exudation possessing deficient vitality, sometimes grey, but more frequently of a yellowish color, varying in size, form, and consistence, essentially composed of molecules and irregularly-formed nuclei. Forms of tubercle.—These may be distinguished as—1st, Miliary tubercle, existing in small grains like millet-seeds, and which may bo yellow or grey, hard or soft; 2d, Infiltrated tubercle, existing in masses or patches more or less extensive ; 3d, Encysted tubercle—that is, masses of tubercle surrounded by a fibrous cyst; 4th, Cretaceous and calcareous tubercle—that is, tubercle loaded with mineral matter, sometimes break- ing down under the finger, and at others of stony hardness. In this way tubercle not only varies in form, but in extent, color, and consistence. It may be diffluent, soft, cheesy, waxy, indurated, chalky, and calcareous. Minute structure of tubercle.—A small portion squeezed between Fig. 157. Fig. 158. Fig. 159. glasses, and examined under the microscope, presents a number of irregu- larly-shaped bodies, approaching a round, oval, or triangular form, and Fig. 157. Corpuscles from firm tubercular exudation into the lung, a, After the addition of acetic acid. Fig 158. Corpuscles, granules, and debris, from soft tubercular exudation into the cerebellum. Fig. 159. The same, from tubercular infiltration of a mesenteric gland. 250 diam. ISO PRINCIPLES OF MEDICINE. varying in their longest diameters from the 20V0 to T2V0 0I" au inch. These bodies contain from one to seven granules, are unaffected by water, but rendered transparent by acetic acid. They are what have been called tubercle corpuscles. They are always mingled with a multitude of mole- cules and granules, which are more numerous the softer the tubercle. Occasionally, when softened tubercle resembles pus, constituting scrofu- lous purulent matter, we find the corpuscles more rounded, and approach- ing the character of pus cells. They do not always, however, on the addition of acetic acid, exhibit the peculiar granular nuclei of pus cells. Fig- ICO. Fig. 161. The grey granulations described by Bayle may seem, on careful management of the light, and after the addition of acetic acid, to contain similar bodies to those described as tubercle corpuscles, being closely aggregated together, having indistinct edges, and containing few granules. Cretaceous and calcareous tubercles, on the other hand, contain very few corpuscles, their substance being principally made up of numerous irregular masses of phosphate of lime, and a greater or less number of mi- neral molecules and crystals of cholesterinc. Tubercle corpuscles may be associated with pus and granule cells, as well as with cells peculiar to glandular organs or mucous surfaces in various stages of fatty trans- formation and disintegration. -0i " 0 ° 0?J®vO Oft ft ? 2 o o O.^'&o @0Q3 °cj CNM10 ^3°0 Fig. 162. With all these they have frequently been confounded! Everything that I have seen of tubercle tends to convince me that it Fig. 160. Section of a firm miliary tubercle of the lung •FiS' fiif ^ S-f?\ °f1 a grey ?ranulation k the lung, showing the pulmonary vesicles filled with tubercle corpuscles. p Half' 162" M0leCUkr StTUCtUre 0f a ^Icareous pulmonary tubercle.-tfadclyfe 250 diam. TUBERCULOSIS. 181 consists of an exudation which has little tendency to pass into cell-forms. The original albuminous molecular matter melts into nuclei, which con- stitute the tubercle corpuscles, and are developed no further. It has been regarded by some pathologists as a breaking-down of pre-existing textures, and by Virchow as forming in the interior of connective tissue corpuscles. The former view is based upon the circumstance that cells in the act of breaking down may be observed in a certain stage to present irregularly-shaped nuclei with numerous molecules, which closely resemble those found in tubercle, as in chronic pneumonia and in the reticulum of cancer. I feel persuaded, however, that tubercle is a histogenetic, and not a histolytic process, and that as such it may easily be demonstrated in every organ which it attacks. That it is caused by a pre-existing growth in the so-called connective tissue corpuscles, is open to the same objections that I made to the supposed origin of pus in the same bodies. In no case can it be demonstrated. Chemical composition of tubercle.—Tubercle has been analysed by numerous chemists. The general results are as follows:—1st, That tubercle consists of an animal matter, mixed with certain earthy salts. 2d, That the relative proportion of these varies in different specimens of tubercle. That animal matter is most abundant in recent and earthy salts in chronic tubercle. 3d, That the animal matter consists almost wholly of albumen, mixed with a minute quantity of fibrin and fat. 4th, That the earthy salts are principally composed of the insoluble phosphate and carbonate of lime, with a small portion of the soluble salts of soda. 5th, That very little difference in ultimate composition has been detected between recent tubercle and other albuminous compounds. Pathology of tubercle.—In endeavoring to determine the nature of tubercle, we must remember that it occurs in young persons in whom the nutritive functions are deficient in energy, whether from poverty and incapacity of obtaining food, from deficient stamina, or from causes of whatever kind which induce exhaustion. Hence its frequency among the ill-fed poor, in orphan and foundling institutions, among badly- nursed children or weak and dyspeptic young persons, and after acute inflammations, whooping-cough, eruptive fevers, and other disorders that weaken the body. When, under such circumstances, exudation occurs in one or more textures, it does not undergo those changes we observe following inflammation in healthy persons. The vital changes are slow, and easily arrested. Instead of cells and perfect textures being produced, the efforts at vital transformations are abortive. The whole remains molecular and granular, or at most ill-formed nuclei are produced, which have received the name of tubercle corpuscles. It is rare, however, that this weakness of the constitution acts uniformly at all times and in all textures. Hence it may frequently be observed that tubercle is more or less associated with pus and granule cells, or fibrous and other growths; with the exception of cancer, with which it is rarely combined. I regard tubercle, therefore, as an exudation, which may be poured out into all vascular textures in the same manner and by the same mechanism as occurs in inflammation, only from deficiency of vital power it is incapable of undergoing the same transformations, and 182 PRINCIPLES OF MEDICINE. exhibits low and abortive attempts at organisation, and more frequently, as a result, disintegration and ulceration. For the same reason we observe that whenever an undoubted inflammation becomes chronic with weakness, the symptoms and general phenomena become identical with those of tuberculosis. Hence there is little difference between a chronic pneumonia of the apex of a lung and a phthisis; the one, indeed, pass- ing into the other. When we endeavor to discover the origin of the weakness produc- ing this effect on the exudation, we must ascribe it to imperfect nutrition; indeed, it is impossible for any observant practitioner to avoid noticing throughout the whole course of the disease the derangement that occurs in the digestive system. All writers refer to the deficiency and irregu- larity of the appetite, and the functions of the whole alimentary canal will be found from first to last in an abnormal condition: the tongue is either furred and furrowed, or glazed and unusually red; the teeth are carious; the stomach capricious—sometimes rejecting foo^d, at others retaining it an unusual time, with accumulation of flatus. There is a general indisposition to eat fat or fatty substances ; and the appetite is feeble, absent, or, in rare cases, voracious. In the former case there is thirst and eructation of acid matters into the mouth; flatulence and tympanitis of the bowels are frequently complained of; the alvine discharges and egesta are as irregular as the food and ingesta. Some- times there is constipation, at others diarrhoea. The stools are only slightly tinged with bile, and in children often consist of white glairy matter, like white of egg. It may also be invariably observed, that when, by proper regulation of the diet, of exercise, or other circumstances which regulate the nutritive functions, the alimentary canal performs its duty, the health improves, and the tubercular formations diminish. These, indeed, according to their excess or progress in particular organs, communicate to the disease more or less of a local character. In systematic works they have been described at length as separate diseases, although, in truth, they are only manifestations of one disease. After a time the continuance or violence of the local disease reacts upon the constitution, and a state called hectic fever is established, the which, inducing exhausting diaphoresis and emaciation, ultimately de- stroys the patient. Natural progress of tuberculosis.—In tracing, therefore, the natural progress of tuberculosis, we observe it to commence in debility caused by impairment of nutrition. This leads to local congestions and exudations. The latter remain abortive, and consist of molecules, granules, and imperfect nuclei, which soften and cause ulceration, with more or less disorganisation. The great contribution of M. Louis to the pathology of this subject was the establishment of a law, that whenever tubercle occurred in the body it also existed in the lungs, and whenever it occurred in the lungs it appeared first at the apex. This law, though now known to be subject to several exceptions, is still so generally correct as to be of the utmost service in diagnosis. Now, in the lungs, it was long supposed, and the opinion is still very general, that tubercle almost always proceeded onwards to a fatal termination; yet so far is this from being the fact that it can easily be shown that tubercle is TUBERCULOSIS. 183 arrested spontaneously in one-third of all the persons in whom it occurs. Nothing is more common in examining dead bodies than to meet with crectaceous and calcareous concretions at the apices of the lungs more or less associated with cicatrices. Of seventy-three bodies which I ex- amined consecutively some years ago in the Royal Infirmary, I found these lesions in twenty-eight. Of these, puckerings existed with indura- tion alone in twelve, with cretaceous or calcareous concretions in sixteen. Since then I have examined many hundred lungs at the inspections in the Infirmary, and am satisfied that these proportions exist pretty constantly. At the Salpetriere Hospital in Paris, Roger found them in fifty-one bodies out of a hundred; at the Bicetre Hospital, in the same city, Boudet found them in 116 out of 135 bodies. Both these institu- tions are establishments for persons above seventy years of age. These lesions are so frequent, therefore, that it is important to determine whether they are really proofs of arrested tubercle. This seems to be established by the following facts:— 1. A form of indurated tubercle is frequently met with, gritty to the feel, which, on being dried, closely resembles cretaceous concretions. 2. These concretions are found exactly in the same situation as tuber- cular deposits are. Thus they are most common in the lungs, and at their apices. 3. When the lung is the seat of tubercular infiltration throughout, whilst recent tubercle occupies the inferior portion, and older tubercle and perhaps caverns the superior, the cretaceous and calcareous concretions will be found at the apex. 4. A comparison of the opposite lungs will frequently show, that whilst on one side there is firm encysted tubercle, partly transformed into cretaceous matter, on the other the transformation is perfect, and has occasionally even passed into a substance of stony hardness. 5. The puckerings found without these concretions exactly resemble those in which they exist. Moreover, whilst puckering with grey induration may be found at the apex of one lung, a puckering surrounding a concretion maybe found in the apex of the other. 6. The seat of cicatrices admit of the same exceptions as the seat of tubercles, and in about the same proportion. There can be no question, therefore, that these cicatrices and concretions for the most part indicate the arrestment, disintegration, and transformation of pre- existing tubercular exudations into the lungs. The arrestment of tubercle in the lung is not confined, however, to its early stage. It may be stopped at any period, and numerous cases are now known where even vast tubercular caverns have healed and cicatrised. I here show you a series of preparations, which must con- vince the most sceptical of the truth of this statement.* Treatment.—It follows, therefore, that if we can succeed in support- ing the nutritive functions, there is no reason why tubercle once formed should not be gradually absorbed, and a tendency to subsequent deposits completely checked. Formerly this was rarely accomplished, in conse- quence of the idea that phthisis pulmonalis ought to be treated by paying attention especially to the lungs and respiration. Hence cough mixtures, sedatives, a warm atmosphere, tar vapor, and other substances to influ- * See the author's work, "The Pathology and Treatment of Pulmonary Con- sumption," 2d edition, Figs. 21 to 26. 184 PRINCIPLES OF MEDICINE. ence the local lesion. Other symptoms had their special treatment, such as sulphuric acid to relieve sweating, acetate of lead and opium to check hemoptysis, tonics to give strength, astringents to check diarrhoea, and so on; while so far from any vigorous effort being made to improve nutrition, the diet was kept low, consisting of farinaceous substances, or, at most, milk; and to avoid irritation, the patients were confined to bed or their rooms, which were kept at an equable temperature. Our present knowledge has led to a complete revolution in our prac- tice. Thus, moderate exercise to stimulate respiration, cold sponging, nutritious diet, and a bracing system, have been found more beneficial; at the same time avoiding anodynes and cough mixtures, which, by diminishing the appetite and inducing weakness, interfere with nutrition. Indeed, it has been proved that.the best method of lessening cough, ex- pectoration, and sweating, are the means which produce increase of gene- ral strength ; so that, if we can carry out the general indication, the local symptoms may be safely left to themselves. In doing this, we have now the advantage of possessing a remedy which, in cases of tuberculosis, is of the highest nutritive importance, as it gives to the system that fatty element in which it is so defective, and in a form that is more easily assimilated, and more capable of adding to the molecular element of the body, than any other. I allude to cod- liver oil. And now, you cannot fail to perceive how the molecular doctrine of organization and of growth not only explains the known facts in physi- ology and pathology, but constitutes the basis for a true therapeutics. Fatty particles, as we have seen, form the molecular fluid of chyle; while out of chyle, blood, and through it all the tissues, are formed. Impair- ment of digestion in scrofula and tuberculosis renders chylification im- perfect ; the fatty constituents of the food are not separated from it and assimilated; the blood consequently abounds in the albuminous elements, and when exuded forms, as we have seen, tubercle. To induce health, it is necessary to restore the nutritive elements which are diminished, and this is done directly by adding a pure animal oil to the food. While an inflammatory exudation in previously healthy persons should be treated by supporting the vital powers generally, so as to permit its molecules going through the transformations necessary for their growth and elimin- ation ; in tuberculosis we add the constituent of food necessary for the formation of the molecules themselves. By so doing, we form good chyle and blood ; we restore the balance of nutrition which has been disturbed; respiration is again active in the excretion of carbonic acid gas; the tissues once more attract from the blood the elements so necessary for their sustenance. The entire economy is renovated; so that, while the histogenetic processes are revived, the histolytic changes in the tubercle itself also are stimulated, and the whole disappears. When, in 1841. I first announced the virtues of cod-liver oil as an analeptic or nutrient in this class of cases,* so little was the substance known, that linseed oil was furnished to the Royal Infirmary of this city instead of it, when I induced Dr. Spittal to try it in his wards. At present, I need scarcely AppIndL^ SeTuttTlm1111 '***"*> 1M1" ^ ^° ^ *™ ™k' ** MORBID GROWTHS. 185 say, whole fleets are engaged in transporting the oil from the extensive fisheries, where it is manufactured for medicinal purposes ; and its bene- ficial results are universally recognised. In 1852, Dr. Wood of Philadelphia remarks of it, in his Practice of Physic (see vol. ii., p. 95, note), that in Philadelphia, during the ten years from 1840 to 1849 inclusive, the average proportion of mortality from phthisis was 1 in about G'76 from all causes, or 14-8 per cent, and the same average existed in previous years. Cod-liver oil was then gene- rally used in its treatment, and the mortality sank in this disease during 1850-51 to 1 in 8-33, or about 12 per cent, and in 1851 it was only 1T86 per cent. In 1862, Dr. C. J. B. Williams, in one of the Lumleian Lectures delivered to the London College of Physicians, observes, that the experi- ence of Louis and Laennec gave an average duration of two years' life in phthisis, after it was decidedly developed, but that since cod-liver oil was introduced, he infers, from 7000 cases, that the average duration of life has been four years—that is, doubled. My own conviction is, that innumerable cases which formerly would have died rapidly, now rally, live for years, and many of them ultimately recover. The hopelessness which used to seize upon many consumptive persons, and on their friends, is also now removed, and the resolution to combat the disease by appropriate diet, exercise, and other hygienic means, has added further success to our treatment. I venture then to say, that in the same manner that in recent times we have diminished the mortality in cases of acute inflammation, so we have diminished the mortality and increased the duration of life in cases of tuberculosis, and more especially in that most fatal form of it—phthisis pulmonalis. In the one disease, as in the other, the improvement can only justly be ascribed to the advance of physiology and pathology ; to our superior knowledge of the nature of the disease, and, as a conse- quence, to our treatment of it on more scientific and successful principles. MORBID GROWTHS OF TEXTURE—THEIR GENERAL PATHOLOGY AND TREATMENT. The exclusive study of morbid growths, according as they affect in- ternal or external parts, has led to limited views of the subject. The surgical tendency to speak of them as tumors, and to regard them in reference to the great practical question of excision, has interfered with the true pathological doctrine—namely, that, however or wherever pro- duced, they are essentially the same. No doubt they are very common i i external parts, simply because all growth proceeds best on surfaces where there is room for expansion, but this accidental circumstance should not induce us to suppose that they are peculiarly matters for surgical consideration. In truth, their study belongs to pathology—that science which constitutes the basis of all branches of the medical art. The line which separates health from disease is not always to be determined, when certain tissues or organs have increased in size dispro- portioned to the rest of the body. Exercise, within certain limits, may 186 PRINCIPLES OF MEDICINE. cause the size of particular parts to be relatively increased, as the legs of the dancer, and arms of the blacksmith. In these cases, however, such enlargement is consistent with health. So when the uterus enlarges and its walls thicken during pregnancy, we recognise that the departure from the normal type is absolutely necessary for the purpose it is required to carry out; and when this is accomplished, it returns to its natural condition. In like manner, other hollow viscera enlarge when they have an obstruction to overcome. Thus the urinary bladder becomes greatly thickened, in consequence of a stricture in the urethra; and the left ventricle of the heart becomes hypertrophied from disease of the aortic valves. But in these last cases, the increased growth, though a wise adaptation of nature, and even necessary for the continuance of life, must be regarded as evidence of permanent disease. Again, a blow on the breast, on the skin, or over a bone, may cause the injured parts slowly to enlarge, inducing swellings, which may produce inconvenience from their size, or from their pressure on neighboring nerves. In this manner, no tissue or organ of the body is exempt from more or less increase of its extent or magnitude, and there are none, consequently, which may not occasionally present morbid or excessive growth. Increased growth of tissues may assume various forms. The organ or structure may gradually become enlarged in whole or in part, still maintaining more or less of its original texture, shape, and function, con- stituting hypertrophy. Membranes may become preternaturally thickened, causing more or less induration, whereby the movements of parts may be affected, or the calibre of tubes and ducts may be diminished, producing stricture. The results of the healing process may give rise to new tissues exactly resembling those previously existing in other parts of the body, as in cicatrices, callus, etc.; or such growths may assume the form of tumor. Lastly, we must not overlook the fact that certain transforma- tions in the exudation, formerly noticed, lead to increase of texture, and produce morbid growths altogether foreign to the healthy frame. A cultivation of histology excited the hope that, by studying the ultimate structure and mode of development of morbid growths, distinc- tive elements, and thereby a new foundation for their classification, would be discovered. But extensive researches long ago convinced me that this hope was vain, and in a special work, published in 1849,* I pointed out what were the ultimate elements of all morbid growths, and that not one of these was characteristic of any special kind of organic formation. The structural elements of morbid growths may be reduced to six, viz.—1st, molecules and granules; 2d, nuclei; 3d, cells; 4th, fibres; 5th, tubes (especially vascular ones); and 6th, crystals or irregular masses of mineral matter. Now no combination of these elements will serve to characterise morbid growths, such as fibro-molecular, fibro-nucleated, fibro-cellular, fibro-vascular, etc., for the simple reason that tumors very unlike in their external characters and natures may be composed of the same elements. For instance, cystic, glandular, cartilaginous, and can- cerous_growths, are all fibro-cellular. It is not then from its showing the existence of one or more elementary structures, but from its pointing at their mode of arrangement, that the microscope is destined to be of * On Cancerous and Cancroid Growths. Edinburgh, 1849. CLASSIFICATION OF MORBID GROWTHS. 187 infinite importance in pathology and diagnosis. Neither will chemical composition furnish us with trustworthy means of distinguishing morbid growths, as many of them contain albuminous, fatty, pigmentary, and mineral principles conjoined, although in variable proportions. The best classification, therefore, is one founded on our knowledge of the compound textures of the growths themselves, assisted as far as varieties are concerned by their similitude to well-known objects, which have long been received in pathology as standards of comparison. Thus the following arrangement appears to me capable of embracing all the known primary classes of morbid growths :— I. Fibrous growths . . . Fibroma* or Inoma. II. Fatty growths . . . Lipoma. III. Cystic growths . . . Cystoma. IV. Glandular growths . . . Andenoma. V. Epithelial growths . . . Epithelioma. VI. Vascular growths . . . Angionoma. VII. Cartilaginous growths . . Enchondroma. VIII. Osseous growths . ft. Osteoma. IX. Cancerous growths . . . Carcinoma. All these primary divisions are susceptible of being subdivided according to the presence of particular substances, or to fancied resem- blances which have received names. Thus the varieties of the above kinds of growth have long been determined by their substance present- ing greater or less similitude to well-known objects, such as water, lard, flesh, brain, etc. etc., as follows: Hygroma. Melanoma. Chloroma. Hasinatoina. Colloma. Steatoma. Atheroma. Meliceroma. Cholesteatoma. Sarcoma. Neuroma. Encephaloma. Myeloma. Schirrhoma, etc. It is easy to understand how varieties may in this way be multiplied, and how new names may be scientifically given to rare forms of tumor, for instance Syphonoma, or tubular growth, described by Henle ;f Cylin- droma, by Billroth;| Seteradenoma, by Robin,§ etc. etc. * The word Fibroma, though composed of a Latin root with a Greek termination, and therefore barbarous, is here given in consequence of its having been already em- ployed in medicine. Those, however, who may object to it on this ground, can employ the more correct novel term of Inoma, from ls-lvos, a fibre. f Zeit fur. Rati6n. Med. 3 Bd. 1 Heft. ± Ueber die Entwicklung der Blutgefasse, Berlin, 1856. § Traite d'Anat. Pathologique, par Lebert, p. 339, ct seq. 1. Like water 2. i. black pigment 3. a green pigment 4. u blood 5. <( glue 6. a lard 7. a gruel 8. a honey 9. it cholesterine 10. a flesh 11. it nerve 12. n brain 13. u marrow 14. u marble 188 PRINCIPLES OF MEDICINE. Further varieties have been made to express one or more combina- tions of these elements, and hence the terms Fibro-cystic, Fibro cartilagi- nous, Fibro-Sarcoma, Osteo-Sarcoma, and so on. Indeed, this kind of nomenclature admits of further extension, and such terms as Fibro- epithelial, Angio-cystic, Cystic-adenoma, Osteo-fibrous, and so on, might be employed with advantage. When, also, growths have a certain re- semblance to, or largely partake of the character of the structures and substances referred to, while their real nature is not absolutely or alto- gether the same, the words Fibroid, Cystoid, Adenoid, Ckondroid, Osteoid, Colloid, LTcematoid, Fungoid, Encephaloid, Myeloid, Cancroid, etc., have been employed. All these words and modes of expression, as they, are founded on anatomical facts, may, if carefully applied, be useful in designating the structure and nature of morbid growths. But other distinctions founded on presumed vital properties, are objectionable. What ideas, for instance, can be attached to the terms innocent and malignant ? A fibrous growth has been generally classed among innocent ones, yet the terms recurrent and malignant have also been applied to it. In fact, we shall afterwards see that almost every kind of growth may be innocent in some cases, and malignant in others. The distinctions, therefore, sought to be established from such theoretical considerations are not only erroneous, but have proved—as we shall subsequently show—most injurious in practice. I have known innocent growths never operated on by the surgeon, and allowed to kill, in consequence of his believing them to be malignant, and really malignant ones not touched at that early period when their removal was likely to be beneficial, in the hope that they would go away of themselves. This point will be more especially dwelt upon, after giving, as it is now proposed to do, a short sketch of the nine distinct kinds of morbid growths. Fibrous Growths.—Fibroma or Inoma. The pathological formation of fibrous growths is the most common b c and universal which occurs in the <& ess I f ess BPiPB Pm body. I* is essentially of two kinds— 1st, a simple increase by division or enlargement of pre-existing fibrous tissue; 2d, a new formation of fibres in an exudation. I. As examples of the first kind of increased fibrous growth, we may refer to what takes place in voluntary and involuntary muscle, in simple hyper- trophy. In voluntary muscle, the fas- ciculi and fibrillae increase in breadth, Fig-163- and there is a tendency to fissiparous Fig. 163 Structures in hypertrophied heart, a, A muscular fasciculus dividing dichotomously; b a slender fasciculus dividing; c, anastomosing fasciculi; rf, con- centric ; e, smooth colloid (amyloid ?) bodies.- ( Wedl.) 250 diam FIBROUS GROWTHS. 1°* division whereby they become more numerous. There may be also observed fasciculi varying greatly in size, but without cells such as are visible in embryonic muscular formation. The same thing occurs m hypertrophy of non-voluntary muscle, where, in addition to great increase of bulk in individual cells, other smaller ones in various stages of devel- opment may also be detected. In the uterus during pregnancy this is easily observable, but in the thickening of organic muscular fibre of the stomach and other hollow viscera, the large elongated fusiform cells are not discoverable. Fig. 164. Fig. 165. II. With regard to the second kind of increased fibrous growth, it may be said to present various forms. We have previously seen that the coagulation of liquor sanguinis often occurs in the form of filaments (Fig. 138), which become more and more dense. These are molecular fibres. Occasionally when the exudation coagulates, it presents a tendency to fibrillate or split up, Fig. 166, Fig. 167. Fig. 168. Fig. 16?. owing apparently to the formation of nuclei, which become more or less elongated. These are nuclear fibres. At other times cells are formed, which elongate, become fusiform, split up, and so produce fibres in the manner described by Schwann in healthy tissues. These are cell fibres. In these three ways, there may be produced all kinds and forms of fibrous Fig. 164. Fibrous structure of the uterus. Fig. 165. The same, hypertrophied from great increase in size of its fusiform cells. Fig. 166. Cell fibres and fibre-cells from a fibro-cellular growth in the coats of the stomach. Fig. 167. Fusiform cells from a sarcomatous growth in the kidney. (See also Fig. 213.) Fig. 168. Fibro-nucleated structure, from a so-called medullary sarcoma of the humerus. Fig. 169. Fibrous stroma of a tumor acted on by acetic acid. 250 diam. 190 PRINCIPLES OF MEDICINE. element, from the finest and most delicate areolar tissue, to one resembling in consistence ligament or fibro-cartilage. Hence, as far as structure is concerned, we may have fibro-molecular, fibro-nucleated, and fibro- cellular fibrous growths. 1. One of the most common forms of pathological fibrous tissues is that of cicatrix, which is generally produced in the same manner in every tissue and organ. The exudation in such cases is partly transformed into filaments, and partly into pus. The former are in connection with the deep-seated tissues and capillaries, and are covered and protected by the latter. On examining a fungous granulation on the surface of a wound, it may be seen to contain round, oval, caudate, and fusiform cells, in all stages of their development towards fibres. As these increase in amount and become approximated, the formation of pus gradually ceases. At length the new growth reaches the surface of the healthy tissue, con- tracts, causing more or less puckering of the surrounding structures, and becomes dense like ligament. (See Fig. 151.) 2. Another form of pathological fibrous growth occurs after the sub- cutaneous section of tendons, and in the coats of some hollow viscera. In this case the exudation | thrown out fibril- ' lates, oval or fusi- form nuclei are formed, which are scattered irregularly through the mass, and the whole often have seen the coats of Fig. 170. 172. Fig. 171. assumes a remarkable degree of toughness. We the stomach above an inch thick from this cause, entirely independent of cancerous formation. (Fig. 170.) 3. A third form of pathological fibrous growth is the result of chronic exudation on serous membranes. The white patches so frequently seen, more especially on the pericardium, pleura, and peritoneum, are owing to this cause (Fig. 171). Occasionally such membranes are connected by bands of firm fibrous tissue, or closely united and hypertrophied into a dense, white ligamentous substance, upwards of half an inch thick, as may frequently be seen in the pleurae over chronic tubercular lungs. 4. A fourth form of pathological fibrous growth is seen in an increase of the areolar tissue of the skin, or other organs, and also results from exudation. Thus we observe peculiar thickening and indurations of the skin, owing to this cause, in the adult, and in the hide-bound skin of certain foetuses. Atrophy of parts may arise as a consequence, through pressure thereby produced; for instance muscle may be converted into a ligamentous substance. So called cirrhosis of the liver, lung, and kidney, are owing to a similar cause. Fig. 170. Fibres, from induration of the stomach, with embedded nuclei. Fig. 171. Fibrous tissue, with free nuclei and fusiform cells, from a white patch on the peritoneum. Fig. 172. The same, after the addition of acetic acid. 250 diam FIBROUS GROWTHS. 191 5. A fifth form of pathological fibrous growth is that of tumor. Under this head must be classed a number of growths, hitherto denomi- nated sarcoma and neuroma, as well as those usually called fibrous. They all consist of a fibrous structure, in different stages of development, the softer and more vascular forms being such, even when their substance has not yet completely passed into perfect fibres. For this reason they have been made to constitute a distinct group by Lebert, under the name of fibro-plastic tumors, and may be fibro-nuclear or fibro-cellular in structure. Such growths, however, may always be seen passing into true fibrous tissue. In some, whilst one part of a tumor is sarcomatous, or fleshy, another is truly fibrous; but the difference is only one of develop- ment, and cannot therefore constitute a good ground of distinction. Other kinds of fibrous tumors resemble tough ligament and fibro- cartilage, and present a variety of intermediate conditions of form be- tween the areolar and elastic tissues. Fibrous tumors, therefore, may be divided into—1st, Sarcomatous; 2d, Dermoid; and 3d, Neuromatous Fibrous Tumors. Sarcomatous or soft fibrous Tumors.—These tumors are either spherical or more or less lobulated (pancreated sarcoma of Abernethy). The first are of the consistence of muscular tissue, or very soft cartilage, and are generally surrounded by a distinct cyst. On section, they pre- sent a smooth or finely granular surface. Their color varies from a yellowish-white to a rose-pink or deep red, and is dependent on their degree of vascularity. Occasionally a section presents different colors, the external portion being more vascular than the internal; or it is more or less mottled, the red tint alternating with the yellow. At other times the section presents several ecchymotic spots, varying in size, caused by extravasation of blood from the capillaries. Owing to the vascularity of these tumors, there is a disposition in them to exudation, and to a breaking down of their substance, with formation of purulent fluid. For the most part, they increase in size slowly, and only cause in- convenience from their bulk, or by pressure on neighboring nerves and tissues. Owing to this pressure, they may induce absorption or ulcera- tion of the parts around them. Not unfrequently these tumors are more soft and lobulated, and have in consequence been frequently mistaken for encephaloma. The lobules vary greatly in size, and present externally a papillary, or cauli- flower form, sometimes resembling the pancreas, and hence the name given to them by Abernethy. Occasionally the lobules are surrounded by a more or less dense layer of areolar tissue. They are, for the most part, of a greyish, yellowish, or rosy color, their tint varying with their amount of vascularity. These tumors are found in many places, as below the skin, richly supplied with cellular and fibrous tissue. They are not unfrequently observed in the mamma, where their separation from schirrus constitutes one of the nicest points of surgical diagnosis. They may occur in bone, and have received the name of osteosarcoma, although many tumors that have received this name have been shewn to be cancerous. They constitute small mushroom-like growths on the conjunctiva (Lebert), and may destroy the eye from the pressure caused by their enlargement. 192 PRINCIPLES OF MEDICINE. The minute structure of these sarcomatous tumors is essentially fibrous, but many of the fibres are seen to be made up of congeries of fusiform cells closely applied together (Figs. 175, 213) These cells are of a spindle shape, varying in length and breadth, and are for the most Fig. 173. Fig 174. Fig. 175. Fig. 176. part distinctly nucleated. Many of them may be seen branched at their extremities, and passing into fibres, according to the mode of develop- Fig. 177. Fig. 178. Fig. 179. " Fig. 180. ment of fibrous tissue described by Schwann. In some, the nueleus has disappeared. Other of the cells are round or oval, or only slightly elongated. All these stages of a fibro-cellular growth may be observed in the same tumor. In the softer parts, isolated cells and nuclei abound (Fig. 173), whereas, in the harder and denser parts, the develop- ment into fibrous tissue is perfect (Figs. 175, 176). At other times associated with the fibres we find a multitude of oval nuclei, without cells of any kind. These I described in 1849 Fig. 173. Cells in the soft part of a fibrous tumor removed from the neck by Mr. Syme. Fig. 174. The same, after the addition of acetic acid. Fig. 175. Fibres in various stages of development from a harder nodule of the same tumor. Fig. 176. Perfect fibrous tissue from another nodule of considerable density. Fig. 177. Corpuscles scraped from the surface of a fibro-nucleated growth of the thigh, excised by Mr. Miller. Fig. 178. The same, after the addition of acetic acid. Fig. 179. Appearance of a thin section of the tumor. Fig. 180. Another section treated with acetic acid. FIBROUS GROWTHS. 193 as fibro-nucleated growths. They may be hard or soft, and present the structure represented Figs. 177 to 180, and 168. Some tumors of this kind are so soft, as to be pulpy in their consistence, and contain between the meshes of their fibro- cellular structure a certain amount of serous liquid. These are soft polypi. For the most part, they constitute pro- minences on the mucous membrane, to which they are attached by a neck, which may be broad or narrow (Fig. 181). Ex- ternally, they are covered with mucous membrane, more or less hypertrophied and thickened (Fig. 184). Fig. 181. Fig. 182. Fig. 183. Fig. 184. Fig. 185. Dermoid or hard fibrous tumors.—These tumors are generally of a white color, more or less tough and elastic, resembling the well-known §ES structure of the dermis. This, indeed, is gps not so apparent in examining the compara- ■ tively thin human dermis; but on looking at that of some of the larger animals, and more especially of the whale, the analogy in structure at once becomes evident. These tumors are of a rounded or oval form, frequently embedded in a cyst, composed of the indurated structures in which they lie. They are of considerable density, vary- ing from that of tendon to that of ligament Fig. 186. " or fibro-cartilage, and on section present numerous white glistening fibres, intimately interwoven together, or arranged in bundles constituting circles, or loops intercrossing with Fig. 181. Soft polypi growing from the Schneiderian mucous membrane—(Liston). —Half natural size. Fig. 182. Fibre cells and fibres from the pulpy interior of a polypus removed by Mr. Syme. Fig. 183. The same, after the addition of acetic acid. Fig. 184. Ciliated epithelial and pus cells from the exterior of the tumor. Fig. 185. The same, after the addition of acetic acid. 250 diam. Fig. 186. Section of a dermoid fibrous tumor, embedded in the uterine walla. One-fourth of the entire growth is represented. Natural size. 13 194 PRINCIPLES OF MEDICINE. each other. Occasionally they have a calcareous centre or nucleus. Their color is generally white, but sometimes they have a yellowish tinge. They are for the most part not very vascular, although there is great difference in this respect, some approaching the pinkish color of sarcomatous growths, and others being of dead white and of extreme density, containing scarcely any vessels. They vary greatly in size, from that of a pin's head to a volume measuring several feet in circumference. These tumors may be situated in various tissues and organs, as in the subcutaneous and submucous cellular tissue, in the mamma, and uterus, in which last-named organ they are most common. When ally the pedicle breaks across, and the tumor becomes free in the serous cavity. To the same cause are owing the small fibrous, oval or round bodies, called loose cartilages, found in the joints, more especially -that of the knee, some of which are truly osteo-cartilaginous. Others are found in the veins, and denominated phlebolites. The minute structure of these dermoid tumors is found to consist FIBROUS GROWTHS. 195 (Fig. 188), and sometimes they are isolated, as in the sarcomatous tumors; but then the proportion of them to the fibrous element is generally small. The bony nuclei of such tumors are composed of amorphous mineral matter, not of true bone (see Fig. 368), although Le- bert says, that on two occasions he has seen true bone produced. Wedl also has figured true bone in the interior of these growths (see Fig. 282). The two forms of fibrous growth now spoken of may frequently be found associated together in one tumor. Some are composed of several rounded or oval masses varying in size, enclosed and separated from each other by a cyst, or layer of areolar tissue. The external surface, under such circumstances, is more or less nodulated. It may frequently be observed that some of these nodules are soft and pulpy—semi-gelatinous, with a very sparing layer of fibrous tissue; whilst others may be seen more or less tough, gradually passing into a fibro-cartilaginous density, grating under the knife. Nay, even in the same nodule I have frequently observed some parts of it soft and others hard, and have shown that the softer parts are mostly cellular, and the harder fibrous, and that between the two there are many degrees of variation. Neuromatous Fibrous Tumors.—This form of fibrous tumor is developed in the nerves, sometimes spontaneously, at others as the result of injuries, and especially of amputa- tion. In the museum of the Rich- mond Hospital, Dublin, I examined a most remarkable series of preparations taken from two individuals, in whom almost every nerve of the body pre- sented knotty swellings. In some places these were developed into tu- mors, which varied in size from a pea to that of the human head.* A subcutaneous tumor, described by the late Mr. W. Wood, of Edinburgh, must be referred to this class of tumors, f All these neuromata, on being minutely examined, are found to con- sist of fibrous texture, more or less dense, the filaments often arranged in wavy bundles running parallel to each other, but occasionally assum- ing a looped form, or intercrossing with each other, as in Fig. 186. I have also found them to contain groups of cells, so that, on the addition of acetic acid, they closely resemble the structure represented Fig. 188. Not unfrequently they are fibro-cartilaginous, sometimes with the cells closely aggregated together, at others widely scattered (Fig. 190). In some of the neuromatous swellings described by Dr. Smith, of Dublin * *See Smith's Treatise on Neuroma; Dublin, 1849. f Edin. Med. and Surg. Journal, 1812. Fig. 189. Section of neuroma connected with three nervous trunks.—Natural size.—(Smith.) 196 PRINCIPLES OF MEDICINE. I found the fibrous tissue to present wavy bundles, among which a few y/i/ // Fi.z. 19X Fig. 191. granule and cartilage cells were scattered and shrivelled, apparently from the action of spirit (Fig. 191). Fatty Growths.—Lipoma. The morbid increase of fat is frequently so imperceptible, that it is impossible to separate the pathological from the physiological state. Obesity may gradually increase, either locally or generally, internally or externally, so as to cause, not only inconvenience, but actual disease. Some individuals have become celebrated from their excessive fatness. (See Polysarcia.) Fat sometimes occurs in masses, being only an exaggeration of the normal texture of the part, as when it collects about the heart, in the omentum, or on the serous membranes, in which case it takes the exact form of the included viscera. Fat may also be aggregated in masses in unusual situations, and then form the so-called fatty tumor Fatty tumors vary in size; they may reach a growth weighing up- wards of 30 lbs. Sometimes their surface is lobulated, at others smooth. Ihey are of a yellow color, resembling adipose tissue, and are occasion- ally divided into bands by white fibrous tissue. The relative amount ot these two elements varies greatly in different specimens, some being soft oily, containing few fibres, others being hard and dense, the areolar tissue preponderating. For the most part they are very sparingly supplied with blood-vessels; the vessels abound most in the fibres ItZT; ^ lteT CaSG,the? are liable t0 ulcerate. a*d, under such circumstances, have frequently been mistaken for cancer. Some of these SmWd'l^ '^^ rsidered aS fibrou« or sarcomatous tumors, ^P^wi.811 TSUd T™^ 0f fat Occasionally they are con^ nected with the ordinary adipose tissue of the body. We see this in fatty tumors so common in the subcutaneous tissue. They are often Sf Hi ?mlnour8^nctt^8fbCUtaneOUS tubOTcle> imposed of fibro-cartilage. * 250 diam. FATTY GROWTHS. 197 surrounded by a delicate cyst or envelope; but in others this is not per- ft" ^ Fig. 192. ceptible. It is when the collection of fat resembles the ordinary adipose tissue, that the tumor has received the name of Lipoma. When it is more lardaceous, some have applied to it the term Steatoma, in the same manner as when the substance is encysted. When firm, and largely mingled with fibres, it may be called Fibro-Lipomatous, as in the" lobu- ^ lated tumors that constitute so frightful a de- ft| ft ■£. Jj formity of the nose (Fig. 192). *> c< Cells developing endo- genously, independent of the nucleus, which is embedded in the wall of the narent cell; de, the sames undergoing the fatty degeneration; /, q, cylindrical epitheuum 2^raySa b0Ve= A' Perithelium £lls : I, fibreSlS^SS) Fig. 208 Structure of cholesteatoma, consisting of disintegrated fat vesicles and epithelial scales with numerous crystals of cholesterine.-(^«l) HTdiam (LisloZ.) J ^ Wlth fatty steato™tous contents. Natural sne.- CYSTIC GROWTHS. 203 tion,—the granular fatty matter of oil globules and granules mixed with broken-up crystals, epithelial scales, and sometimes the products of fibri- nous exudation (Figs. 208, 210). Such is the general structure of the atheromatous encysted growths of various authors. / 0V:®/ Vftv ®o°.' W.V ™ ft > . f.yOsT® ® >^> •J'-'-ft.^ft^Vo.-^ /o v;-;'1 isv © /&. ,^\? •ft**. 'v^< •ft /i-Vft ?.° • Tft-i Fig. 210. Fig. 211. Again, the fatty matter may be more or less lardaceous in character, and consists of beautiful round or oval cells, some of which are distinctly nucleated. Mixed with these may be a granular matter, combined with epithelial cells or their debris (Fig. 211.) At other times no distinct cells can be observed, only a granular or amorphous mass, the greater part of which is soluble in ether. This constitutes the steatomatous en- cysted growth (Fig. 209). 6. Many encysted growths contain hair and teeth. The hair is occa- sionally inserted into the walls of the cyst, at other- times lies loose in it, mixed with the fatty or other contents. The hair has exactly the same structure as the hairs in other parts of the body, having distinct bulbous roots. When attached they are surrounded by a follicle in the lining membrane : when loose they have been evidently grown in follicles, and been afterwards separated. Their apices are frequently split up into several fibres in the longitudinal direction. The teeth belong sometimes to the first, and sometimes to the second dentition. They present on section the usual structure of cav- ity, with ivory, enamel, and bone. Sometimes they are found em- bedded in a follicle of the lining membrane, at others like the hairs, they are quite unattached. 7. Occasionally the cysts con- tain lymph, or softened fibrin, pre- senting the structure of molecules Fig- 212. (Fig. 212), or of pus and granule cells—this is the result of exudation into their cavities. Occasionally there is a serous fluid more or less Fig. 210. Contents of a large atheromatous cyst, opened by Mr. Syme, consisting of numerous crystals of cholesterine, oily granules, granule and pus cells, with en- closed cysts containing oil granules.—(Murchison.) 200 diam. Fig. 211. Adipose cells, embedded in fatty granular matter from a steatomatous encysted tumor of the ovary. 250 diam. Fig. 212. Cysts in cystic-sarcoma of the mamma, filled with molecular matter. 204 PRINCIPLES OF MEDICINE. ^ mixed up with extravasated blood, giving to the contained liquid various colors and appearances, according to the age of the extravasation Ihus it maybe red, dark brown (resembling coffee), of a dark-greenish tinge, etc. etc. Sometimes it is of a dark bluish or blackish tint from excess of pigmentary deposit. 8. Sometimes the contents of the cystic growth are formed ot a solid exudation,which has undergone the sarcomatous trans- formation as previously described, and wholly consists of fusiform cells (Fig. 213). The exudation poured into such cysts may pass into the cancerous forma- tion, and then the characters we have described will be associated with those which distinguish cancer. 9. Some cysts contain the peculiar secretion of the organ in which they are found. Thus cysts in the liver may be full of bile, and those in the kidney of urine 10. Lastly, cysts may contain a greater or smaller amount of mineral matter. The mode in which encysted growths are developed is—1st, By the hypertrophy of pre-existing tissues, whereby, from the accumulation of materials within, canals are distended, follicles or vesicles enlarged, and their walls thickened. Thus the simple cysts in the plexus choroides are owing to effusion of serum into the areolar spaces in the villi of the membrane and their subsequent distension. Those in the kidney may be owing to the dilatation of uri- niferous tubes above an acci- dental obstruction, in the same manner that the whole kidney may become encysted from obstruction of the ureter. The Malpighian capsules also, or the shut sacs of the thyroid, may be distended with fluid, which thus forms cysts. In like manner the crypts of the skin, the blind sacs of conglobate glands or of the follicles of mucous membranes, become obstruct- ed at their orifice ; and their contents gradually accumu- lating, distend the walls, Fig. 214. which become enlarged and thickened. Fig. 215. Simple cysts in the ovary become dilated by enlargement of isolated Graafian vesicles, either Fig. 213. Fibrous tissue composed of fusiform corpuscles, from a sarcomatous encysted growth in the kidney. 250 diam. Fig. 214. Cystic-osteoma of the femur. One-eighth the natural size.—(Miller.) Fig. 215. Cystic-osteoma of the tibia. One-eighth the natural size.—(Miller, copied from the preparations referred to.) CYSTIC GROWTHS. 205 deep in the stroma of the organ, or on the surface, when they grow out- wards, and become pedunculated. This mode of cystic formation, from distension by material that can- not readily find an escape, is remarkably well observed in bones, in which cysts are sometimes produced in consequence of accumulated pus. In the Edinburgh University Museum is a remarkable preparation, in which a large osseous cyst has been developed in this manner, at the lower end of the femur (Fig. 214); and in the Edinburgh College of Surgeons' Museum, is another, which has formed in a similar manner in the head of the tibia (Fig. 215). In the first specimen the osseous cystic walls are thin, in the second they are greatly thickened. In this respect they resemble the cranial bones, which in some cases are ex- panded and rendered thin, and under other circumstances become pre- ternaturally thick through disease. 2d, The origin of compound encysted tumors is not so well deter- mined. It is very probable, however, that in most cases they consist of clusters of simple cysts, which become compressed together, assume an increased power of growth, and are at length surrounded by a capsule. They are most common in the ovary; and here we can readily under- stand how successive growths of Graafian vesicles may give rise either to the appearance of secondary or tertiary cysts, or to the multilocular form we have described. Once produced, the compound cyst enlarges, the in- dividual ones grow sometimes inwards and sometimes outwards, accord- ing as there is more room for expansion in the one direction or the other. In the former case they open into each other by ulceration. Hence, in very old compound cystic growths, we find one large cavity with the traces on its internal wall of previously existing cysts, or bands and divisions with pouches between them. In the latter case they grow outwards, forming clusters of cysts more or less pedunculated, as in the Fig. 216. Fig. 217. so-called hydatid moles of the chorion. These endogenous and exogenous modes of growth are sometimes found in the same specimen. 3d, Another mode in which compound cysts are formed is by the Fig. 216. Cysts in cystic-sarcoma of the mamma, crowded with cells; a, the cells after the addition of acetic acid. Fig. 217. Fibrous stroma from another part of the same tumor, with commencing enlargement of the areolar spaces, after the addition of acetic acid. 250 diam. 206 PRINCIPLES OF MEDICINE. gradual enlargement of the areolae in newly formed fibrous tissue. On examining thin sections of sarcomatous growths, we observe the fila- mentous tissue arranged in a circular form, enclosing spaces varying in size. These spaces are often lined by a distinct epithelial membrane, and sometimes contain serum, blood, or exudation, either in a granular or fibrous state. Such growths have long been known under the name of cystic sarcoma (Figs. 216, 217, and also Figs. 200, 212). 4th, The glandular or epithelial cells of an organ assume an in- creased power of development, and become scattered through its tissue in great numbers. In the kidney especially, a cystic disease is not un- frequently met with, in which the cysts vary from the size of a pea down to the ToVotn or* an *nch m diameter, as may be accurately traced with the aid of the microscope. The diagnosis and treatment of encysted growth belong to the special pathology of each organ affected by them. It need only be mentioned here that a knowledge of the structure of these tumors is not unimportant, as an examination of the fluid discharged from them frequently enables us to speak with certainty regarding their nature. Glandular Growths.—Adenoma. Glandular growths are essentially hypertrophies of gland texture, in the same manner that fibrous or fatty growths are an increase of fibrous Fig. 218. or fatty tissues. But the structure of a gland is compound, and embraces two kinds of growth. Strictly speaking, the growths are fibro-epithelial, but of a kind so peculiar as to warrant Lebert and Birkett in constitut- ing them into separate groups. * Iig^18'-JSt^UC^Ure °f ? cystic glandular tumor of the neck, in the neighborhood of the thyroid gland, a, Appearance of a portion slightly separated and viewed by a simple lens, presenting a grape-like bunch of lobules; b, c, d, ultimate lobules, com- posed of single or branched caecal tubes, distended with epithelial cells; *, distended condition of these on the addition of water; /, alteration of their shape on pressure; g, fusiform cells found in small numbers.— (Redfern.) 250 diim. GLANDUXAR GROWTHS. 207 Glandular growths may be regular or irregular, that is, they may in- volve the entire gland or only a portion of it, and in the latter case they may assume the form of tumor. They may also be perfect or imperfect, in the first case closely resembling the gland structure, in the second differing from it in various degrees, and passing into fibrous, cystic, fatty, and other forms of growth. It is not our intention to enter into minute descriptions of the various appearances and modifications of structure they present in the several glands. Under the names of chronic mam- mary tumor, bronchocele, enlarged prostate, and hypertrophied, in- durated, or swollen glands, their existence was recognized before their structure was known. While now it has become apparent that growths, which are truly glandular in their nature, have frequently been mistaken for fibrous and even for cancerous formations. These growths are sometimes lobulated, with the lobes more or less compressed, and the interlobular fibrous tissue varying in density and amount. They may reach a considerable size. One, removed from the female breast by Mr. Syme, which I carefully examined, was larger than the human adult head, and weighed upwards of eight pounds. To the feel they vary in density, are lobular or smooth externally, and in the latter case are not unfrequently surrounded by a fibrous capsule. On section they are sometimes smooth and glistening, at others somewhat granular and dull. The cut surface varies in color, sometimes being almost white, at others of a pale yellow, pink, or fawn color, apparently from the greater or less amount of vascularity of the particular specimen. Their mode of growth is by no means uniform. Sometimes they remain indolent and stationary, then again they increase steadily in size, slowly Figs. 219 220, and 221. Structure of a glandular tumor, surrounded by a fibrous cyst removed from the female mamma. Fig. 219. Thin section transverse to the glandular lobules, after the addition of acetic acid, showing the condensed epithelial lining membrane and enclosed epithelium cells. Fig. 220. a, Mass of epithelium separated from the cut lobule; b, cellular contents; c, the same, after the addition of acetic acid. Fig. 221. Longitudinal section of one of the ducts leading from the lobules, after the addition of acetic acid. 250 diam 208 PRINCIPLES OF MEDICINE. at one time and rapidly at another. Occasionally, after giving rise to much anxiety, they gradually disappear, but not unfrequently they pre- sent all the external characters and symptoms of fibrous or sarcomatous tumors, and now and then those of true cancer. In structure, glandular tumors consist of gland elements—that is to say, of a basement membrane, furnished with blood-vessels on one side, and nucleated cells or nuclei on the other. Their firmness, softness, and friability, depend upon the amount of fibrous tissue in them, and upon the number of cells. The follicles are frequently much distended, presenting blind sacs apparently without ducts, and are crowded with epithelial cells, more or less compressed together. If ducts do communi- cate with them, these are similarly distended, as seen in Fig. 221. The thyroid gland is especially liable to a new formation of tissue, first described by Rokitan- sky, in which embedded in a lax fibrous stroma are round- ed vesicles, surrounded by a layer of delicate pavement epithelium, and containing colloid substance, which es- capes when one of these is ruptured, Fig. 222, a, R* Whether the remarkable structure denominated by M. Robin, " Tumeur Heterade- nique,"f in any way resem- bles this, it is difficult for me to say, never having had an opportunity of examining a specimen. Lymphatic glands are very liable to enlarge through lo- cal irritation, arising from a neighboring ulcer or injury; and the mesenteric glands are especially so, in conse- In typhoid fever >ftft Fig. 222. quence of the various ulcers which form in the intestines they are frequently found swollen as large as hens' eggs, presenting a reddish or purple hue externally, soft and spongy to the feel, on section exhibiting a granular texture and greyish hue, and on pressure yielding a dirty white juice. This juice abounds in the cell elements of the gland, which exhibit an increased power of development. The cells enlarge, * Zur Anatomie des Kropfes, Wien, 1849. _ ___f Lebert's Anatomie Pathologipue General et Speciale, Liv. 10,11. Fig. 222. New formed tissue in "a follicle" of The" thyroid gland. A, Areolar fibrous tissue surrounding the epithelial-Uke lining of the areola}. Many of these have been removed to show the glandular formations within. These vary in shape, some, b, d, being constricted, others round or oval—a, c. B, Colloid masses of various shape from the interior of a. g, Epithelium, with commencing fatty de- generation, seen also at d, e, and /. h, Blood-vessels containing colorless corpuscles of the gland.-( Wedl.) b 250 ^ GLANDULAR GROWTHS. 209 their nuclei divide into two, these increase by division into four, or a multiple of two, and often form a cluster in the centre of the cell, as seen in the accompanying figures (Figs. 223, 224). The causes which excite glandular growths are not always apparent. They maybe constitutional .6>^j,oVft:ftift.-. ^%^;9:W" and local, and in the latter ''•''^Va- "'S® ft4ft-%v^ 2. The scaly skin diseases must be classified among epidermic growths. Accumulations of epidermic scales, upon a reddened and indurated surface, constitute their characteristic features. In psoriasis they are gathered together in considerable masses. In pityriasis the scales are smaller are more easily separated from the surface, and frequently associated with minute cryptogamic 'vegetations. The flattened and imbricated form of ichthyosis is also composed of similar accumulations of epidermic scales, but without the reddened surface. (Fig. 115). 3. Warts and Condylomata are also, for the most part, composed of epidermic cells condensed together. The wart consists of projections of a papillary form, varying in. size, and occurs ^ under circum- stances where pressure does not take place. These growths appear to be constitutional, or associated with peculiar states of the Ffg. 226. Fig. 227. body. Thus condylomata and warts are frequently found round the mar- gins of the anus, vulva, and penis, in syph- ilitic individuals. Warts assuming the form of cauliflower excrescence, often ar- rive at a large size in such situations, weighing even several pounds. They fre- quently form on the hands of young per- sons, and are sometimes found on other parts of the body, coming and going with- out any obvious cause. Condylomata, when closely examined, seem to be made up of a congeries of pa- ro(0 pillae {papilloma), sometimes flattened at (pv~" the top so that they cannot be separated ; (Q/^ at others, presenting fissures or sulci which lead down to a common stalk. Sometimes the papillae are small and rounded; at others, elongated and enlarged at their extremities. The tumors thu3 formed Fig. 228. may be only the size of a pin's head, or may be so large as to weigh Fig. 226. Warts on the penis. One-fourth the natural size.—(Acton.) Fig. 227. Summit of a papilla from a wart. Fig. 228. Perpendicular section of a papilla from an acuminate condyloma, after the addition of acetic acid, a, Vascular loop—internal to which is fibrous tissue forming the axis of the papilla—outside are nucleL b, b, Basement membrane, c, c, Epidermic cells.—(Wedl.) 250 diam. 212 PRINCIPLES OF MEDICINE. Fig. 229. several pounds. In the latter case the central portions seem to consist of a fibrous structure, probably an hypertrophy of the dermis, which is supplied with blood-vessels (Fig. 229). Their surface sometimes is smooth, resembling thickened epidermis; at others it is lobulated, composed of rounded groups of papillae, resembling externally a cauli- flower. These tumors, when small, are almost wholly composed of epithelial scales, which assume a square or elongated form, their nuclei being for the most part very distinct. In the larger growths the surface is similarly composed, but internally we find more or less areolar tissue, supplied with blood-vessels. On snipping off a small isolated papilla from such a tumor, and examining it entire, it pre- sents a conical or round projection, covered with epidermic scales, as in Fig. 227. When a vertical section of it is made, we observe a vascular loop, surrounded by basement membrane, external to which are layers of epithelial cells varying in thickness (Fig. 228). The Verruca Achro- cordon is a peculiar epidermic tumor, furnished with a cen- tral canal, through which blood-vessels ramify abun- dantly to all parts of the tu- mor. The central parts of such tumors are composed of fib rous structure (Fig. 229); exter- nally they consist of epidermic scales, arranged concentrical- ly round the central vascular part, which, if cut into, gives rise to great haemorrhage.— ( Vogel.) All these tumors may soften, and ulcerate on the surface, and, under such cir- cumstances, give rise to purulent and ichorous dis- charges. 4. Another form of epithe- lioma is one which frequently commences as an ulcer, al- though sometimes it is pre- ceded by slight induration of, or a small wart on the part affected. It is common in the under lip, in the tongue, and in the cervix uteri. In the lip there may be often observed a furrow or groove in the indurated spot or wart, in which the ulceration commences. This slowly extends, with indurated, thickened, and raised margins, is circular and cup-shaped, its Fig. 229. Transverse section of the base of a condyloma. The dark shading in the centre and radiating lines, represent dense fibrous vascular tissue.__(Wedl.) Fig. 230. Ulcerated epithelioma of the lip.—(Liston.) EPITHELIAL GROWTHS. 213 surface sometimes covered with a white cheesy matter, at others with a thick crust or scab (Fig. 230). It slowly extends, until it involves a greater or less portion of the lip and neighboring parts, pouring forth a foul ichorous discharge. In the tongue, the disease follows a similar course; the base of the sore, however, is generally more fungoid or papillated on the surface, and exceedingly dense, owing to the close impaction and compression to- gether of lamina? of epitheli- um. These on section present a mass having a white surface, with a tendency to split up and separate, are dense to the feel, and do not yield on pres- sure a milky juice (Fig. 231). On the cervix uteri similar ulcers are very common, with hard irregular edges, yielding a copious ichorous discharge, and causing more or less thickening of the neighboring textures. The so-called cauli- flower excrescence is a form of epithelioma; so also are the cancer of the scrotum of the chimney-sweeper, certain forms of rodent ulcer, and of noli me tanqere. An epithelioma of the hand is well figured by Mr. Paget,* and so also is a remarkable one in the interior of the stomach by Professor A. Retzius.f Fig. 231. Fig. 232. Fig. 233. In all these cases, the ulcers, when examined microscopically, present * Surgical Pathology, vol. ii. p. 41*7. f Museum Anatomicum Holmiense. Sect. Path. Tab. 1. 1855. Fig. 231. Section of an ulcerated epithelioma of the tongue. Natural size. Fig. 232. Muscular tissue immediately below the white mass Fig. 231. Fig. 233. Concentric laminse of condensed epithelial scales, from the lower por- tion of the white matter seen Fig. 231, with epithelial cells, and fragments of muscular fasciculi. 250 diam' 214 PRINCIPLES OF MEDICINE. on the surface masses of epithelial cells in all stages of their development. Some spherical and nucleated are about the ToVo*h 0I> an inch in diameter, others are much larger; both often resembling cancer-cella when isolated or viewed alone, but associated with flattened scales, vary- ing in shape and size, sometimes occurring in groups adherent at their edges> at others mingled together in a confused mass. Many of the cells and scales often reach an enormous size, and as they become old, split up into fibres. These elements are commonly mingled with .numerous molecules and granules, naked nuclei, fusiform, granular, and pus cells. Below the surface the epithelial cells may be seen more or less compressed and condensed together, and when the epithelioma is chronic, and the structure dense, these present concentric lamina? sur- rounding a hollow space or loculus, evidently owing to the compression together of numerous epithelial scales. This peculiar appearance, some- Fig. 235. Fig. £34. Fig. 236. times called "cell nests," is characteristic of this form of epithelioma (Fig. 233). On breaking them up, they exhibit a variety of forms, in which their epithelial character is visible on the one hand, and the fragments of concentric circles are seen on the other (Fig. 237.) The lymphatic glands in the neighborhood of such ulcers have a great tendency to be secondarily affected, in which case they enlarge, soften, and easily break down under the finger. Not unfrequently they contain a yellow cheesy-looking substance, which, under such circum- stances, represents fatty degeneration, analogous to the reticulum of cancerous formations. On crushing a portion of the altered glandular substance between glasses, it presents the appearances represented Fig. 237. If the concentric masses are broken down, the individual epithelial cells are here also seen to be of various fantastic shapes, in which fragmentary portions of circles are detectable (Fig. 237). In thg Fig. 234. Epidermic scales, in mass and isolated, from the surface of an epitheli- oma of the scrotum, in a chimney sweep. Fig. 235. Group of deep-seated cells, in the same case. Fig. 236. The same, after the addition of acetic acid. 250 diam. EPITHELIAL GROWTHS. 215 yellowish portions the nuclei are composed of fatty granules, and the Fig. 237. Fig. 238. cells themselves are molecular, and mingled with numerous oily particles, (Fig. 238, also Fig. 122). A modification of this form of epithelioma occurs on mucous surfaces, especially in the urinary bladder, && °s\® <2ft OpOs Fig. 240. and has been variously called villous cancer, dendritic vegeta- tion (Zottenkrebs of Rokitans- ky). It forms a fungous projec- tion, having a fibrous basis which is elongated into branched stems, supporting villi, more or less aggregated together, and covered with a layer of epithe- lial cells. It is soft, and readi- Fi£-m ly breaks down under the finger, the pulpy matter exhibiting under the microscope numerous irregularly-shaped cells, partly fibrous and partly epithelial, in various stages of development (Fig. 239). 5. Hairy formations.—Great varieties exist in different individuals regarding the amount of hair on their body. Some men have been known to be as hairy as certain of the lower animals. Patches or groups of hair, seated on a somewhat indurated base, may frequently be seen scattered over the surface in parts usually smooth; these constitute a form of so- called mole on the skin. Hair has been found on the surface of the mucous membrane, and even in the lungs; and is common in encysted tumors, especially of the ovary and testis. In several such cases I have found the root of the hair implanted in a follicle, at other times loose, with the roots of a bulbous form exactly resembling those on other parts of the body. The point of the hair is generally somewhat truncated, presenting at its extremity two or more fibres, produced by the longi- Fig. 237. Fragments produced by breaking up the concentric masses figured, Fig. 233, from a lymphatic gland. Fig. 238. Epithelial cells, in yellow cheesy matter, of the same gland. Fig. 239. Cells in pultaceous white matter, from a fungoid epithelioma of the Urinary bladder. Fig. 240. The same after the addition of acetic acid. 250 diam. 216 PRINCIPLES OF MEDICINE. tudinal splitting up of the hair. In length they vary from one quarter of an inch to several inches. G. Horny productions.—Under this head may be classed the promi- nent growths in some forms of ichthyosis; tu- mors resembling warts, but so indurated as to resemble horn, and true horny ex- crescences growing from the surface. In some forms of ich- thyosis, the growths stand out as distinct spines, broad on the surface, narrow at their insertions, like col- umns of many sides, accu- rately fitting to their neigh- bors. Horny tumors occa- sionally occur, varying in size from a bean, or extend- ing over a space the size of half-a-crown. Many cases are on record of true horn having grown from the sur- face, especially from the head, originating in some sebaceous follicle. They have grown several inches long, as seen in Fig. 241. On making asection of these productions, they are found to be identical with the *'=•-"■ structure of true horn in the lower animals, or with that of the nails on the hands and toes. They consist of condensed epidermic scales, which on the addition of acetic acid, assume all the characters of such structures. Vascular Growths.—Anyionoma. Vascular growths are formed by an increase in the dimensions or number of the arterial, capillary, or venous vessels. Several growths already described, as well as such as are of a cancerous nature, are very vascular;—indeed, so much so, that in some cases the slightest touch causes alarming haemorrhage, as in the case of so-called uterine polypi, and fungus hgematodes. No doubt there is considerable increase of vas- Fig. 241. Froman old preparation in the Edinburgh University Museum. The medal attached to it bears the following quaint inscription :—" This horn was cut by Arthur Semple, Chirurgeon, out of the head of Elizabeth Low, being three inches above the right ear, before these witnesses, Andrew Temple, Thomas Burne, George Smith, John Smytone, and Jame3 Tweedie, the 14th of May, 1671.—It was growing seven years ; her age 50 years. Natural size. VASCULAR GROWTHS. 211 cular growth in such tumors, but their basis is formed of other material— they are not wholly vascular. This term is more properly applied to those diseases which have hitherto been denomi- nated aneurism, erectile tumors, and varix. 1. Aneurism is an arterial swelling, which may vary in size from the slightest possible dilatation of the calibre of the vessel, either wholly or partially, to the formation of enor- mous tumors, larger than the human head. Fig. 242. In such cases, we find the growth to consist externally of the dilated and hypertrophied structures of the vessel itself, or of the tissues in its immediate neighborhood, and of layers of blood, more or less coagulated within it. The varieties of aneurism are numerous, but the principal are—1. Aneurism by dilatation, in which the whole circumference of the vessel pig. 243. is dilated. 2. Saccular, also called true Aneurism, in which one portion or side of the vessel is dilated into a sac. 3. False Aneurism, in which the coats of a vessel have been ruptured. It has been called primitive when all the coats are divided, as by a wound, and consecutive, when it is consequent on ulceration or rupture of the internal and middle coats. 4. Mixed Aneurism, in which, after dilatation, general or partial, of all the coats of a vessel, the internal and middle ones burst, and a false aneurism is superadded. 5. Dissecting Aneurism, in which there is laceration of the internal and middle coats, so that the blood becomes infiltrated between the coats of the vessel, separates them for a greater or less distance, and bursts externally at some distance from the internal lesion. 6. Hernial Aneurism, in which the external and middle coats are lacerated, and the internal protrudes through them, forming a her- nial aneurismal sac. 7. Aneurism by anastomosis, in which an artery, by an unnatural communication with the vein, causes a pulsating tumor in the latter. The tendency of these growths is to burst externally or internally Fig. 242. True saccular aneurism of the aorta, nearly filled with coagulated clot.— One-third the real size.—(After Hodgson, slightly modified.) Fig. 243. Remarkable spontaneous varicose aneurism, formed by communication between the vena cava and the aorta at its bifurcation. A, Aorta; B, Vena cava; C, Aneurism; D, Situation of a round aperture somewhat larger than a sixpence, through which the communication between vein and artery was kept up.—(Syme.) 218 PRINCIPLES OF MEDICINE. into spaces where least resistance is offered, but occasionally the clot of blood in the interior coagulates to such an extent as to close up the cavity^ prevent ■ influx of fluid, and cause spontaneous cure—a result which is observable in the figure of a very rare specimen of aneurism of the left coronary artery described by Dr. Pea- cock.* The special pathology of these growths, however, is far too extensive a subject to be entered upon in this place. 2. Erectile growths are generally soft; for the most part situated in the subcutaneous tissue, the skin covering them being of unusual delicacy. When compressed they may be gradually emptied of blood, which returns like water into a sponge on removing the pressure. For the most part they are congenital. When the arteries are numerous in them they haye a brownish or reddish color, and pulsate during life. When the veins abound, they are of a blue or purple color. Their texture con- sists of numerous capillaries, more or less distended, mixed with arteries and veins, the interstices of which are filled up by areolar tissue. A section presents a spongy texture, composed of fibrous bands closely " resembling the appearance of the corpus cavernosum penis, with areola) or spaces into which the blood enters (Fig. 245). The section of a fresh tumor is not unlike that of a sponge soaked in blood. In struc- ture it is composed of vessels of all sizes, abounding in capillaries, which are more or less sacculated or aneurismal, and anastomose freely with each other. In one case of erectile growth in the liver, I found the intervascular structure to consist of caudate and branched cells, and in another, in the brain, I found it loaded with earthy salts. Varix is a permanently enlarged and tortuous vessel. Swellings _______________* Monthly Journal of Medical Science. March, 1849. JVaSs/i-^SSS-f the C°r0nary artery' comPletely fiUed with coagulated clot. Fig. 245. Section of erectile tumor.—(Miller, after ?) wmw^ VASCULAR GROWTHS. 219 from this cause are for the most part venous, and may exist in various parts of the body, but are frequent in the saphena veins of the inferior extremities, the spermatic veins (varicocele), and hgemorrhoidal veins (haemorrhoids). In all these cases the veins gradually enlarge, and then become distended, tortu- ous, and coiled up. Seve- ral of these, accumulated together, may produce knotty swellings in the legs, cause the testicle to assume an unusual size, or produce tumors which, during defaecation, are protruded beyond the margin of the anus. Such growths may ulcerate, and cause death by hsemor- Fig. 246. rhage, or they may be spontaneously obliterated by the formation of clots within them. An artery rarely becomes varicose. The enlargement of vascular growths, for the most part, arises through dilatation of the vessels; no new materials are produced in them, with the occasional exception of such as arise in the clot of blood within them, viz., fibrous or albuminous lamina?, or calcareous masses. Through the presence of these, the vessel becomes obliterated, and gradually assumes the density and appearance of ligament. New vessels constitute one of the most common pathological forma- Fig. 247. tions. In the embryo the capillaries originate in independent cells, which throw out arms or prolongations that unite with one another (Figs. 252 and 253). The larger vessels originate in globular cells which be- come fusiform, and arrange themselves, some longitudinally and others transversely, to constitute the different coats of the vascular wall (Figs. Fig. 246. Varicose vessels in the caput trigonum vesica?.—(Wedl.) 200 diam. Fig. 24*7. Inner layer of umbilical artery of calf, eight inches long.—(Drummond.) Fig. 248. Succeeding layer in the same vessel, composed of spindle-shaped cor- puscles.—(Drummond.) Figs. 249 and 250. Layers more external in the same vessel, in different stages of development into fibres—(Drummond.) Fig. 251. Common carotid artery of an embryo calf two inches in length, showing different directions of the fibre cells.—(Drummond.) 200 diam. 220 PRINCIPLES OF MEDICINE. Fig. 254. Fig. 255. sionally throw out off-shoots or prolongations. Thus in lymph we some- times observe cells, in all stages of development of the spindle-shaped and branched forms, which, according to the observations of Drummond,* and more recently of Billroth,t by their fusion, or by their arrangement side by side, form capillaries of various magnitudes. These capillaries afterwards unite themselves with the pre-existing vessels. Cartilaginous Growths.—Enchondroma. Cartilaginous growths were first described by Miiller, under the * Monthly Journal of Medical Science, November 1854. f Billroth Ueber die Entwicklung der Blutgefiisse, Berlin, 1856. Fig. 252. Stellate cells in the tail of the tadpole, developing into capillary vessels. Fig. 253. Capillary vessels in different stages of formation from stellate cells, in the eye of the foetal calf.—(Drummond.) Fig. 254. Branched cells in lymph exuded on the peritoneum. Fig. 255. Vessels in an early stage of formation, from a colloid tumor of the back. 250 diam. CARTILAGINOUS GROWTHS. 221 name of Enchondroma (Osteochondrophytes of Cruvelhier). In the soft parts, they are surrounded by an envelope of cellular tissue, and in the bones by a bony capsule. In the first case they occur, although, very rarely, in the glands, as in the parotid or mamma. In the second case they are most common in the bones of the extremi- ties. The tumors may be round and smooth, or rough and nodulated from several of them being accumulated together. Though hard to the feel, they often present a peculiar elasticity. They crunch when cut with the knife, usually present a smooth, glistening surface, and are not unfre- quently more or less soft, pulpy, gelatinous, and even diffluent in some parts of their substance. They are rarely met with. In structure, enchondroma presents all the cha- racters of cartilage—that is, nucleated cells vary- ing in size, isolated or in groups, situated in a hyaline substance. A network of filamentous tissue runs through the substance of the tumor, forming areolae, in which blood-vessels ramify. Fig. 257. Fig. 25S. Fig. 259. Within the areolae so formed, the cartilage is found. Thsse two elements vary as regards amount in different tumors. Sometimes the cartilage is in excess, resembling that in young animals, or that in the foetus. At others the fibrous element abounds, the whole being similar in structure to fibro-cartilage. Between these two extremes there is every gradation. Occasionally it presents all the characters of articular cartilage. I have seen all these kinds in one tumor. The cells present an extraordinary variety in their size and form, being sometimes large and embryonic (Fig. 257), at others small (Fig. 260). They may contain from one to twenty Fig. £06. Enchondroma of the hand and fingers. The tumor, of which a section has been made, is enclosed in a bony capsule. One-fifth natural size.—(Miller.) Fig. 257. Structure of a firm nodule in an enchondroma of the humerus. The right of the figure represents, above, mineral deposit in and around the cells, and below, some isolated cartilage corpuscles. Fig. 258. The same, after the addition of acetic acid, rendering the whole, and especially the nucleus, more transparent. Fig. 259. The cartilage cells and fibrous tissue separated and broken up, with numerous molecules in a nodule of the same tumor which was soft and in some places diffluent. 250 diam. 222 PRINCIPLES OF MEDICINE. nuclei. In shape they may be round, oval, irregular, or branched. They may also be associated with numerous granule cells, as in Fig. 260, Fig. 260. Fig. 261. Fig. 262. Fig. 263. from a specimen of enchondroma removed from the integuments of the neck by Mr. Miller, which on section presented the smooth and moist surface of a cut potato.—(Solanoma.) (Figs. 260 to 263.) Not unfrequently a bony nucleus may be observed in a nodule of enchondroma, and sometimes all stages of transformation into perfect bone may be observed in them. Some of the exostoses, to be spoken of immediately, are owing originally to an excess of cartilaginous growth. Fig. 264. Fig. 265. Fig. 266. Enchondromatous tumors are continually mistaken for cancerous growths, a fact pointed out by Muller. They are usually denominated Fig. 260. Small cartilage with round granule cells, in the pulp scraped from a section of an enchondroma, which in color, density, and appearance, closely resembled a potato, or so-called Solanoma. Fig. 261. The same cartilage cells, after the addition of acetic acid. Fig. 262. Thin section of a firm portion of the same tumor. Fig. 263. Fine filaments which interlaced the cells, these having been washed out. Fig. 264. Thin section of an enchondroma, with a bony capsule, growing from the ischium and pubis. Fig. 265. Separated cartilage cells from a softened portion of the same tumor. Fig. 266. The same, rendered more opaque, after the addition of acetic acid. 250 di. CARTILAGINOUS GROWTHS. 223 osteosarcoma. Not unfrequently they soften, and under such circum- stances present all the external characters of what is called soft cancer. This softened portion, even when examined microscopically, may lead to error, as the cartilage cells which then float loose, mixed with granules and the debris of the tumor, very much resemble those in cancerous growths. They may be distinguished, however, by the action of acetic acid, which affects the whole corpuscle alike, instead of producing, as in the case of cancer, a marked difference between the external cell-wall and the nucleus (Figs. 258, 266). Another form of cartilaginous growth is observed in the so-called pulpy degenerations and ulcerations seen in articular cartilage. Goodsir Fig. 267. Fig. 26S. was the first to point out that such ulcerations were in part owing to an increased growth of the cells ; and Redfern, whilst he has confirmed this statement, has described and figured all the various changes observable in those cells, and in the inter-hyaline substance in the different diseases of cartilage in man, and many of the lower animals. In consequence of Fig. 269. his researches it is now ascertained that the cartilage cells enlarge, and, Fig. 267. Diseased human articular cartilage, from a scrofulous joint, showing the enlargement of the corpuscles, the increase of nuclei within them, and their escape into the intercorpuscular softened substance.—(Redfern.) Fig. 268. Similar alteration in costal cartilage of the dog, caused by the passage of a seton thirty-four days before death.—(Redfern.) Fig. 269. Vertical section through diseased articular cartilage of the patella; a, free surface.—(Redfern.) 224 PRINCLPLES OF MEDICINE. as Goodsir pointed out, there are gradually formed within them a mass of secondary ones. These burst into the surrounding hyaline substance, give it unusual softness, and cause it to swell. At the same time the Fig. 270. hyaline substance fibrillates, and splits up, a change best observed on the villous and rough abraded surface bo commonly seen in diseased joints. Mechanical injury inflicted on these structures produces the same results, showing that both it and disease operate by stimulating cell nutrition and growth (Figs. 267 to 270, and 136). Fig. 270. Fibrous projection, from the flocculent surface of a diseased human semi- lunar cartilage.—(Redfern.) 250 diam. Fig. 271. Lateral view of an exostosis, removed from the posterior and inner surface of the humerus two inches from its head, by Mr. Syme. At a, a piece of the tumor has been broken off, showing the cancellated structure of the interior.—(Lister.) Real size. Fig. 272. Part of a section through one of the prominences of the tumor, a, Superficial cartilage; c, a portion of deep-seated cartilage surrounded by dense bone; b, and d, e, calcified cartilage not so dense as the more superficial portions.— (Lister.) Real size. Fig. 273. Section of a portion of the tumor at the line of junction of the calcified cartilage, and the cancellous structure of the interior, the earthy matter having been removed by dilute hydrochloric acid, a, Cartilage with its cells changed by the pro- cess of calcification; b, c, is true bone, containing laminae, lining the excavations in the calcified cartilage; d, part of a spiculum of the cancellous structure; e, and /, spaces formerly occupied by medullary substance.—(Lister.) 200 diam. OSSEOUS GROWTHS. 225 Osseous Growths.—Osteoma. We have seen that in many of the cartilaginous growths deposit of bone may take place to a greater or less extent. In such cases the new cartilaginous tissue undergoes the true bony transformation, in the same manner that normal cartilage becomes ossified in passing from the foetal state through the periods of youth, manhood, and old age. This we must separate from the numerous forms of calcareous concretions so frequently met with. True bone may be at once recognised by its osseous lacunae and canaliculi. Earthy concretions only consist of an amorphous mass of mineral material. (Compare Figs. 277 and 368.) Osseous growths may affect the external surface, the substance, or the internal surface of bone. In the first case they are denominated exostoses. They form prominences on the surface of the bone varying in size from a small point to that of a cocoa-nut. There is no part of the osseous frame free from them, but they are very common in the bones of the extremities. They may arise as the result of direct local injury, as from a blow or fall, or they may be connected with peculiar constitutional diseases. In syphilitic constitutions, exostoses more especially arise on the shafts of the long bones; in rheumatic persons, they surround the joints. Many of these growths on the surface of bones have not been shown to originate in cartilage as the bones themselves do. But in others, there can be no doubt that such is their mode of growth, viz., matter is thrown out from the blood, which is converted first into cartilage and then into bone (Fig. 273). In this manner enchondroma may be converted into osteoma. The growths in which this change is observable generally present roundish masses. They may be intensely hard or eburnated, or comparatively soft and cancellated. This is owing to the bone texture beiog more compact in the one case and more spongy in the other. Externally they may be covered with a layer of cartilage and a smooth membrane. Bony growths may more especially affect the substance of bones, and this in two ways. An exudation may be poured into the cancelli of the osseous texture, which is gradually transformed into perfect bone. From this cause its substance becomes much indurated and of great density, and the cancelli and medullary cavity are more or less obliterated. We fre- quently observe this in the long bones of the inferior extremity as well as in the flat bones of the cranium. Some of the latter have thus be- come upwards of an inch in thickness, and on section presented the close texture and density, although not the structure, of ivory. Sometimes, however, the bones, instead of being condensed and thickened, become spongy, the cancelli enlarge, and the whole assumes unusual lightness. In this case, the exudation poured into the cancelli is transformed into pus, and acts as a distending power, and sometimes collects in a central cavity, causing at the same time expansion and hypertrophy of the sur- rounding osseous tissue (Figs. 214, 215). On other occasions the new osseous growth assumes the form of spicula, radiating from the shaft, a result most common in cases where the bone is the seat of sarcomatous or cancerous formations, through which they ramify (Fig. 274). 226 PRINCIPLES OK MKOICINE. Bony growths are sometimes thrown out on the internal surface of the cranial bones. This occurs in a peculiar disease first described by Roki- tansky in puerperal women. I saw this formation frequently in Berlin, on the internal sur- face of the cranial bones, in the numerous dissections which oc- curred in the Maternity Hospital of that city during an epidemic puerperal fever which raged there in 1840. Unfortunately, they were not examined micro- scopically. The internal table of the skull in all these cases was so soft, that the knife could readily penetrate it. These de- posits, when dry, assume a gra- nular laminated aspect, more or less curled up and separated from the internal lamina of the cranial bones. Very fine speci- mens of this lesion are to be found in the Pathological Mu- seums of Prague and Vienna. There is a form of growth generally originating in bone, which is soft, easily breaking down under the finger like rice- pudding or marrow (hence called myeloid by Mr. Paget). It has frequently been confounded with soft cancers, as pointed out by Lebert, and in addition to fibrous and fusiform cells, contains others of a round or oval form, vary- ing in size from the g-Joth to the -g^uth of an inch in diame- ter, having in their interior from two to twenty nuclei. These growths occur in va- rious situations, but are most common in bones, es- pecially of the jaw, constitut- ing certain forms of epulis (Figs. 275, 276.) The large cells often contained in the friable matter of such growths (Fig. 276,) closely correspond to the many-nucleated corpuscles described Fig. 274. Spicular growth of bone, in an osteo-carcinomatous tumor of the tibia. One-fourth the natural size.—(Syme.) Fig. 275. Epulis removed from the upper jaw. Natural size.—(Syme.) Fig. 276. Cells with many nuclei in epulis. 250 diam. Fig. 276. OSSEOUS GROWTHS. 227 by Kolliker as occurring in the marrow of foetal bones.* A remarkable example of it is figured by Mr. Paget, occurring in the bones of the cranium, and in the brain.f The growth of new bone, after fractures or injuries, takes place in the following manner :—An exudation is poured out from the vessels in the neighborhood, which at first unites the lacerated edges of ruptured lage. (Fig. 277, a). This carti- Fig. 277. lage, in its turn, is transformed into bone, by exactly the same process as the one structure passes into the other in the normal state. As solidi- fication takes place, the soft parts are absorbed and contracted, whilst the bony growth, in the form of spicula, forming the boundaries of large cancelli (Fig. 277, 0), insinuates itself between and around the fractured bones, producing complete union. Certain textures have been occasionally transformed into true bone. I examined the preparation of an eye at Munich, in the possession of Professor Forg, which contained an osseous mass, attached internally to the choroid and fibrous structure of the sclerotic, and encroaching con siderably on the space usually occupied by the vitreous humor. A thin section of it exhibited numerous bony corpuscles. A similar osseous transformation of the choroid membrane and lens has been described * Manual of Human Histology, vol. i. fig. 7. f Surgical Pathology, vol. ii. p. 222. The peculiar character and structure of these growths may ultimately warrant their being classified among the primary divi sion of tumors, under the name of Myeloma. But at present our acquaintance with them is limited; and the many-nucleated cells, which is their chief characteristic, I have seen in growths presenting all the characters of sarcoma, adenoma, epithelioma, and enchondroma. Fig. 277. a, Fibro-cartilage formed between the separated portions of a fractured cervix femorls ; b, new osseous structure, in the form of a bony spiculum or trabecula between the large cancelli, from the same fracture.—(Wedl.) 250 diam. 228 PRINCIPLES OF MEDICINE. and figured by Dr. Kirk,* in a diseased eye of thirty years' standing (Figs. 278, 279, 280). I have seen true bone formed in the substance Fig. 273. Fig. 279. Fig. 2S0. of the dura mater, where it has been exposed after removal of a portion of the cranium by the trepan. The osseous laminae, sometimes found on the surface of the spinal arachnoid, also possess the true bony struc- ture (Fig. 281). Ligaments have occasionally been transformed into Fig. 281. Fig. 2p2. osseous texture (Henle) ; the calcareous concretions occasionally found in the centre of fibrous tumors, though generally composed of amorphous * Monthly Journal of Medical Science, November, 1853. Fig. 278. Spiculum of bone projecting from the choroid membrane.—(Kirk.) Fig. 279. Section from the centre of the crystalline lens, of stony hardness from osseous transformation. In the centre are spheroidal mineral masses, composed of carbonate mixed with phosphate of lime.—(Kirk.) Fig. 280. Loose membranous matter, like the collapsed pith inside a quill, found in the anterior chamber of the same eye. On one of its surfaces were projecting tubercles with a radiated structure.—(Kirk.) Fig. 281. Ossified excrescence on the arachnoid of the thoracic portion of the spinal cord; at a, a portion is cut across.—(Wedl.) Fig. 282. a, Bony lamina; arranged concentrically; b, others arranged irregularly in partially ossified fibrous tumor of the uterus.—(Wedl.) ° 250 diam. CANCEROUS GROWTHS. 229 mineral matter, are sometimes formed of true bone (Figs. 282, a, b); and Dr. Wilkinson of Manchester communicated to the Pathological Society of that city an instance where numerous muscles of the body had un- dergone a like transformation. In all these cases the osseous structure is formed on a fibrous and not on a cartilaginous basis, an occurrence which may be accounted for by the analogy which exists between carti- lage and certain forms of fibre cells. Many kinds of morbid fibrous growth contain cells and nuclei, which present all degrees of interme- diate formation observable in those of fibrous, cartilaginous, and osseous textures.* (Compare Figs. 187, 277, a, 281, 282). Of earthy depositions which to the naked eye frequently resemble them, whether amorphous or assuming a regular form from accidental circumstances, I shall speak more at length under the head of Concre- tions. Cancerous Gro wths— Carcinoma. Cancerous growths present three principal forms, which result from the relative amount and arrangement of the cells and fibres forming them. 1, A very hard structure, principally formed of fibres (scirrhus). 2, A soft structure containing a copious milky fluid, in which numerous corpuscles swim (encephaloma). 3, A structure having a fibrous basis, so arranged as to form areola? or loculi, which contain a gelatinous gum or glue-like matter (colloid cancer). Fig. 283. Fig. 2S6. Fig. 285. 1. Scirrhus presents to the naked eye a whitish or slightly yellowish tinge, is dense and hard to the feel, and offers considerable resistance * See Memoir on Calcification and Ossification of the Testicle, by Mr. J. S. Gam- gee, in Researches on Pathological Anatomy, etc., 8vo. 1856. Fig. 283. Section showing the arrangement of cells and fibres in scirrhus of the mnmma. Fig. 284. The same, after the addition of acetic acid. Fig. 285. Isolated cancer-cells, from the same growth. Fig. 286. The same, after the addition of acetic acid. 250 diam. 230 PRINCIPLES OF MEDICINE. to, and often crunches under, the knife. On making a thin section of the growth, it is seen to be composed principally of filaments, which vary in size, and run in different directions, sometimes forming waved bands, at others an inextricable plexus, among which, however, nucleated cells (cancer cells) may be seen to be infiltrated. Occasionally the fibrous structure forms loculi or cysts, enclosing similar cells. The so-called cancer-cells may be round, oval, caudate, spindle-shaped, oblong, square, heart-shaped, or of various indescribable forms, produced by pressure on their sides. In size they vary from the xVo o*n to the Ti^th of an inch in diameter. The cell-wall, when young, is smooth and distended; when old, it is more or less corrugated and flaccid. Each cell contains at least one nucleus, often two, and sometimes as many as nine. Most commonly there is only one, which is round, or more generally oval, and contains one or two granules or nucleoli. The nucleus also varies in size, and may occupy from one-sixth to four-fifths of the volume of the Fig. 287. Fig. 288. Fig. 289. Fig. 290. cell. Between the nucleus and cell-wall there is a colorless fluid, which, at first transparent, becomes afterwards opalescent, from the presence of molecules and granules. On the addition of water the cell-wall becomes distended by endosmose, and is enlarged. When acetic acid is added, the cell-wall is rendered more transparent, and in young cells is entirely dis- solved (Fig. 288), whilst the nucleus, on the other hand, either remains unaffected, or its margin becomes thicker, and its substance more or less contracted. 2. Encephaloma also presents a fibrous texture, which, however, is very loose when compared with that of scirrhus. In the denser parts of the growth, indeed, it closely resembles the scirrhus form of cancer, but often where it is pulpy and broken down, no traces of fibres, or at most only some fragments of them, are visible to the naked eye. The whitish cut surface is often more or less mottled, with a pinkish, reddish, greyish, yellowish, or black color. The two first colors are owing to different degrees of vascularity. The reddish spots are owing to extravasations of blood, and are of greater or less extent; when very large they constitute what has been called funyus hosmatodes. The yel- lowish color, when it surrounds extravasations of blood, is owing to imbibition of its coloring matter; but when the color is spread in a reticulated form over the surface, or over masses, it generally results from fatty degeneration of the cancerous tissue, and forms the so-called reticulum (cancer reticulare of Muller). This yellow matter is usually Fig. 287. Young cancer-cells from the lung. Fig. 288. The same, after the addition of acetic acid. Fig. 289. Somewhat older cells from the testicle. Fig. 290. The same, after the addition of acetic acid. 250 diam. Vflu^ft CANCEROUS GROWTHS. 231 of cheese-like consistence, friable, and often resembles tubercle, for which it has been mistaken. The blackish tinge is owing to black pigment ft^-Sft"ft 41 fciiift. iKftfiftvW. ftft*-fti 'ft c-; - o • v« :^.^--^ V ff^fS blood corpuscles, and more or ':" ft _ i ,s ft^ft eft ■ less of the fibrous element. Fig 094 The fibrous structure is the same as that in scirrhus, but the filaments are often finer, and always more widely separated, while the pulpy matter and cells contained in the inter- stices, are correspondingly increased. The yellow reticulum is sometimes composed of loose granules and granular cells, at others of granules alone. Not unfrequently it contains nuclei, disintegrated and altered in shape, with crystals of margarine or of cholesterine. In some instances the en- cephaloma is more or less impregnated with irregular masses of mineral matter, and occasionally is almost entirely converted into a calcareous substance. In this way cancer is liable to undergo the fatty and cal- careous degenerations. (See Fatty and Mineral Degenerations.) Fig. 291. Sill older cancer-cells from a tumor in the duodenum. Fig 292. The same, after the addition of acetic acid. Fig. 293. Highest development of cancer-cells, including secondary cells, from a tumor of the toe. Fig. 294. Simple and compound cancer-cells from the duodenum. Several con- tain fluid from endosmose, which strongly refracts light. 250 diam. 232 PRINCIPLES OF MEDICINE. Fig. 295. when it is formed on a free sur- ace, as on the peritoneum, there are often present small grains of a grey color, resembling coagulated gum-arabic. When collected in masses, Fig. 298. Fig. 29G. Fig. 299. Fig 297. these grains have an irregularly nodulated aspect. I have never seen the fibrous structure of colloid contain permanent nuclei, or afford any evidence of being developed from nuclei or cells. All the three forms of cancer now described are vascular, but in different degrees. Scirrhus is least so, but is still rich in blood-vessels. Fig. 295. Colloid tissue, with the loculi filled with molecular matter, in which cells are commencing to form. On the left of the figure, one of the molecular masses has been squeezed from the fibrous matrix. Below are masses of mineral matter. Fig. 296. Colloid cancer. Appen'nnce of the fibrous areolae filled with cancer-cells. Fig. 297. The same, after the addition of acetic acid. Fig. 298. Some of the cells isolated. Fig. 299. Fibrous stroma deprived of the cells by pressure and washing. 250 diam. GENERAL PATHOLOGY OF MORRID GROWTHS. 233 Encephaloma is always very vascular, and often to such a degree, that it readily bleeds during life (fungus hmmatodes). Colloid cancer is also well supplied with vessels, which ramify among the fibrous tissue. I have already stated that these forms pass into each other, and need only remark here, that this is often so gradual in many specimens, as to render their classification very difficult. This is especially the case with scirrhus and encephaloma. General Pathology of Morbid Growths. The general pathology of morbid growths comprehends a considera- tion of their origin, development, propagation, and decline. It is impos- sible to over-estimate the importance of this subject, as only through a knowledge of it can we arrive at correct principles of treatment. Doubt- less many facts are yet to be discovered ,as to the structure, chemical composition, and mode of formation of morbid growths; but enough has been ascertained of late years by combined histological and clinical research, to necessitate great modifications in the views hitherto held regarding them. The following account is derived not only from care- ful study of what has been written by others, but from a large amount of original investigation. Origin of Morbid Growths.—All morbid growths consist—1st, 0? augmented development of pre-existing textures (the so-called homolo- gous or homeomorphous growths) ; 2d, Of new elements which have no previous existence in the economy (the so-called heterologous or hetero- morphous growths); and 3d, Of these two sorts of growth mingled together. The causes which induce them are of two kinds—1st, Local irritation excited directly or indirectly; and 2d, Constitutional or un- known changes, supposed to operate through the blood. Thus the direct stimulus of a blow may so irritate the parenchyma of a part, as to excite increased nutritive action, and cause hypertrophy, or it may give rise to an exudation; and irritation at a distance may, through the nervous system, produce like effects, as when the female mamma is influenced by the state of the uterus. If, on the other hand, the constitution be affected, such local changes may assume peculiar cha- racters. In this manner, age, sex, hereditary predisposition and various disorders, as syphilis and cancer, not only modify but give rise to mor- bid growths. It has been a favorite idea with pathologists that morbid growths have fixed tendencies from the beginning, such as are impressed upon the ova of various animals, in virtue of which they are necessarily de- veloped in certain directions. If so, this is not traceable to any pecu- liarity of structure or chemical composition. In this respect morbid growths are like healthy ones, which, however different in ultimate com- position, all originate in a finely molecular blastema. A commencing small white nodule of cancer in the stomach, about the size of a split pea, was ascertained by me to present exactly the same kind of molecular matter, exuded in the areolar tissue between the muscular and mucous coats, as occurs in simple exudation. A careful observation of the sub- 234 PRINCIPLES OF MEDICINE. sequent development of these growths, however, seems to indicate that specific differences are not impressed upon them from the first—that one ones. For instance, persons may have a fibrous or glandular growth, and after a time its blood-vessels may pour into it a cancerous exuda- tion, or this latter may undergo a fibrous or fatty transformation. It is only in this manner we can explain numerous cases, which arc daily observable in practice, where indolent fibrous tumors suddenly assume increased power of development and become cancers, or where these last slough out and subsequently cicatrize. Besides these constitutional causes, locality and the nature of pre- existing textures have a considerable influence on the formation of mor- bid growths. Thus, as a general rule, fibrous growths are common in fibrous textures, cartilaginous and bony growths in osseous ones, epithelial growths on epidermic and mucous membranes, and so on. Yet, even here, the particular states of the system generally occasion differences in their modes of manifestation. For example, osseous growths in rheumatic constitutions occur at the extremities of long bones, but in syphilitic ones are found in their shafts. In youth, epithelioma occurs in the form of warts on the hands; in persons touched with syphilis, in the genitals; in chimney-sweeps, on the scrotum; in smokers, on the lips, etc. This conjoined influence of constitutional and local influences indicates the complex nature of the causes which produce morbid growths. A study of these causes is of the greatest moment to the physician, who is desirous of operating upon the local disease through the constitution, or the contrary—as previously explain- ed in the sketch of the function of nutrition. Development of Morbid Growths.—Morbid growths, once formed, continue to grow according to the histological laws which regulate de- velopment in the textures generally—that is to say, after arriving at a certain point, they attract from the blood-vessels in the neighborhood, or from such new ones as are formed within themselves, the nutritive materials whereby they augment in bulk. In voluntary muscular fibre this appears to be accomplished by the fasciculi multiplying fissiparously. They divide as represented (Fig. 163), and hypertrophy is thus occa- sioned by multiplication of parts. In non-voluntary contractile fibre, also, the individual fusiform cells multiply, enlarge, and elongate, a change well observed in the pregnant uterus, in which organ many of the small non-contractile spindle-shaped fibres enlarge, become con- tractile, and then undergo the fatty degeneration, break down, and ultimately disappear (Figs. 165 and 330). In the same manner the Fig. 300. Section of small commencing cancerous nodule, growing from the mu- cous coat of the stomach, showing molecular exudation between the epithelial and muscular coats, a, Epithelium; b, muscular coat. No glands were visible. 250 di. DEVELOPMENT OF MORBID GROWTHS. 235 elementary parts in hypertrophies of other textures, augment fissiparously or endogenously as in bone and cartilage. That this may be the result of local irritation is remarkably well shown by the observation of Bed- fern, who, having made an incision into the cartilage of the patella of a dog, found, on subsequent examination, that the cells had enlarged in the neighborhood of the divided tissue nearest the osseous vessels, as seen Fig. 130. Other forms of morbid growth, especially tumors, are very variable as to rapidity of increase ; but the manner in which the development is accomplished is of three distinct kinds. 1st, The elementary textures are produced in the same manner as they are in adult tissues. They are either more numerous or larger, but preserve their normal relation and mode of arrangement (lipoma, adenoma, anigonoma). 2d, A matter is thrown out from the blood, which serves as a blastema for the forma- tion of cells, which may be detected in various stages of development, undergoing the same changes that similar textures are seen to present in the embryo (fibroma, osteoma). 3d, The cells, whether pre-existing or newly formed, assume such a property of self-multiplication that their normal relation and mode of arrangement is destroyed (epithelioma, enchondroma, carcinoma). These three modes of increase may occur singly or together. Any one or two of them may be superadded to the third, and their occurrence at different times and in various proportions Fig. 301. accounts to a great extent for the apparent anomalies exhibited in the progress of individual growths. The third mode of development just alluded to deserves special con- sideration. It consists of the usual kind of endogenous multiplication of cells, with this difference, that sometimes these cells previously existed, whilst at others they have been newly formed in an exudation. To explain my meaning, I must beg the reader to consult two figures—one by Kolliker (Fig. 301), representing cell structures in the softened articular Fig. 301. Cartilage cells from a velvety articular cartilage of the condyle of the femur of a man.—(Kolliker.) 350 diam. 236 PRINCIPLES OF MEDICINE. cartilage of man, and the other by Redfern (Fig. 302), showing similar formations in a cancerous exudation into the brain. In both a similar Fig. 302. by different names, and have been widely separated pathologically. In the non-vascular cor- nea and cartilage, it has been called inflammation, but in the equally non-vascular epithelium, it has been named cancer. Again, in the vas- cular bones and glands, a cancerous exudation has received various names, such as medullary or osteo-sarcoma, enlarged glands, etc.; whilst in the brain and other localities it has been called encephaloma, or soft cancer. It seems to me that in all these cases the lesion is the same, and therefore that we ought in accordance with their nature to group them together. To call some of them inflammation and others cancer, supposing the first to be innocent and the last malignant, is, I contend, incorrect pathology. True theory points out that all these lesions arc equally destructive, in consequence of increased endogenous cell growth, and practical experience has long determined the question of their being alike difficult to control. As a general rule, the greater the number of cells any growth con- tains, the more rapidly it extends. Hence a tumor is subject to the laws which govern the development and multiplication of cells, in addi- tion to those connected with locality and the general powers of the con- stitution. Thus, room for expansion, and a greater or less amount of temperature and moisture, exercise undoubted influence over morbid growths. We see the influence of room for expansion in the cases of adenoma and carcinoma. In adenoma the cells are confined within pouches or ducts (Figs. 21«, 219). They become crowded on each other; and thus, by means of compression, tend to atrophy and breaking down, rather than to self-multiplication. This is assisted if the distension from within so irritates the fibrous stroma of the gland that it becomes hyper- trophied, and occasions a further obstacle to expansion around the seat of cell increase. In carcinoma, we observe that the growth takes place Fig. 302. Cells from a cancerous tumor of the brain.—(Redfern.) 250 diam. PROPAGATION OF MORBID GROWTHS, 237 in extent and rapidity, proportionally to the number and power of ex- pansion in the cells. If compressed by much fibrous or hard tissue they multiply slowly; but if an ulceration occurs, say in the skin, then they become developed rapidly, and constitute the so-called soft fungoid ex- crescences. Heat and moisture, as they are essential to cell growth throughout the animal and vegetable worlds (increased temperature with fluidity favoring—cold and dryness, checking it within certain limits), so the influence of these physical agents may be observed to be equally powerful in morbid growths. Rapid augmentation of a tumor is gene- rally accompanied by increased heat and softening of the parts, whilst colder and harder swellings develop themselves slowly. Propagation of Morbid Growths.—It has seemed to most patholo- gists that whilst some morbid growths are local, and if removed by the surgeon do not return, others are constitutional or general, and if cut away exhibit a great tendency to come back. The former have been called innocent or benignant, and the latter malignant. So far has the notion of malignancy in certain growths been carried, that surgeons have refused to remove them, not because they were inaccessible, or ?o con- nected with parts as to render the operation directly dangerous to life, but simply because they thought the disease was in the blood, and that cutting away the local swelling would either be useless, or give increased activity to the lesion. Firmly believing that many lives have been sacrificed to this erro- neous principle of practice, I endeavored to combat it in my work on cancerous and cancroid growths, published in 1849. The progress of medical science since then has fully confirmed the truth of my opinions on that subject. Cases are now on record which prove that every kind of morbid growth is malignant, even in the worst sense of those who use that term, and that other growths, which the most experienced surgeons, as well as histologists, have declared to present the typical characters of malignancy, have been repeatedly excised with the greatest success. The establishment of these facts by the many recorded cases which may now be confidently depended on as having been carefully observed, and especially those of M. Velpeau, prove the impropriety of making this distinction between morbid growths. Thus Fibroma, consisting of absolutely nothing but fibres, in all its forms has frequently returned after operation, so that it has received the name of recurrent (Syme, Paget), and it has also invaded every part of the economy. The dermoid variety has been shown by M. Paget, not only to return in the mamma after excision, but to infiltrate itself in the form of numerous distinct nodules throughout the lung.* A somewhat similar case is given by Lawrence,! in an old man, and another in a girl aged six years. Lebert^ has recorded seven cases where sarcoma had spread to the neighboring glands of the original growth, and to various internal organs. Professor Smith of Dublin,^ in a magnificently illustrated memoir, has published two cases in which neuroma occurred in all parts * Surgical Pathology, vol. ii. p. 151, et seq. f On Surgical Cancer, p. 73, 1st edit.; p. 26, 2d edit. f" Traite d'Anatomie Pathologique, p. 195, et seq. § A Treatise on Neuroma, Folio, Dublin, 1849. 238 PRINCIPLES OF MEDICINE. of the body, and Virchow has given a case where neuroma returned in the arm four times, and was four times excised.* Lipoma may be general in the form of excessive obesity, but even when local may return after extirpation.! Murchison has given three cases where multiple fatty tumors were hereditary.^ Angionoma may be so constitutional, that cases have been published in which aneurisms were present in almost every artery in the body.§ Nsevoid tumors, returning after operation in different parts of the body, have been described by Muller and Walther;|| and two others, in which similar vascular growths were dis- seminated among various textures, are given by Cruveilhier % and Laurence.** As regards cystoma, I have frequently been struck in opening dead bodies with the frequency and universality of cystic forma- tions in some of them. In one man I found innumerable sebaceous cysts scattered over the whole anterior surface of the thorax and abdo- men. The constitutional nature of cystoma, moreover, is occasionally demonstrated in cases of bronchocele and mollusca. Adenoma is emi- nently constitutional, the glands being differently affected in a variety of general disorders, as plague, syphilis, scrofula, typhoid fever, etc. Velpeau refers to several cases where it recurred after operation in the same or opposite breast,!! and Aitken has recorded two well-observed instances where, subsequent to the growth having recurred in the mamma, it appeared in the lungs, liver, and ovaries4$ Epithelioma not only spreads to the neighboring glands, but has also been shown by Mr. Paget to infiltrate the lungs and heart, after operations for the removal of similar growths in distant organs.§§ Enchondroma has in- vaded numerous parts, and among others in the same case, the testicles and lungs.|||| Osteoma, composed of true bone (not cancer in bone), has, in a case by Mr. Swan, after affecting the femur, appeared secondarily in the pleura, lungs, omentum, and diaphragm.^[^[ A similar case is given by Laurence.*** Miillerfff has also referred to such constitutional osseous tumors under the name of Osteoids. Of the constitutional characters of carcinoma, I need say nothing. It follows that every kind of morbid growth may be malignant in whatever sense that term be employed, whether used to signify a growth incurable, recurring after the operation or primary lesion; or growths infiltrating neighboring or distant tissues or organs, or as continuing their progress, and destroying life in spite of all the resources of art. On the other hand, it is easy to prove that all these forms of growth may either disappear spontaneously, or be cured successfully by opera- tion, so that the individual may permanently recover. With regard to * Archiv fur Patholog. Anat., Band. xii. p. 114. f Sedillot, Recherches sur le rOancer, 1849, obs. xxix. \ Edinburgh Medical Journal, June 1857. § Cruveilhier. Livraison, 28. Scarpa. Tab. ix. |) Journal der Chir. u. Augenheilk, B. v. p. 261, 1823. 1[ Anatom. Pathologique Gen., torn, iii., 1856. ** On Surgical Cancer, p. 22, 2d edit. \\ Maladies du Sein, p. 404, et seq., 1st edit. ±| Medical Times, April 11, 1857, p. 359. §§ Opus. Cit., vol. ii. pp. 448, 449. ||| Paget in Medico-Chir. Trans., vol. xxxviii. Fichte, (Jeber das Enchondrom, p. 58. Laurence, 2d edit. p. 23. Richet. Gazette des Hospitaux, Nos. 71 and 95, 1855. ^flf Lond. Pathological Trans., vol. vi. p. 317. *** On Surgical Cancer, 2d edit., p. 13. f f f Archiv. fiir Anotomie und Physiologie, 1853, t. v. pp. 396, 442. PROPAGATION OF MORBID GROWTHS. 239 carcinoma this has been denied by some and is doubted by many. On this subject I wrote in 1849 as follows, regarding the permanent re- covery from cancer • " Doubts must always exist, regarding such cases, as long as no authentic record is preserved of the minute examination of the tumor removed. Every experienced surgeon who adopts a favor- able or unfavorable view of this question can point to crowds of cases in support of his opinion; but when he is asked whether the growth operated upon be truly cancer or not, it will be found that he has no positive grounds on which to form a conclusion. He considered it to be cancer, nothing more. In the present state of our knowledge, then, I believe that there is no possibility of pronouncing accurately whether an operation will be successful or not. It appears to me that all analogy opposes the doctrine of the necessarily fatal nature of cancer, or of any other morbid alteration of the economy. There was a time when phthisis pulmonalis was also thought to be necessarily fatal, and when recoveries from it led practitioners to doubt their diagnosis rather than the truth of a received dogma. Morbid anatomy has exploded that error, as it will doubtless do that in regard to cancer." * Since then, M. Velpeau, in a work published in 1854, has proved the correctness of these statements, and has shown that cases which not only presented all the characters of scirrhoma and encephaloma, but which were proved to be so by careful histological examination, have been successfully extirpated without returning. Some of these cases are truly remarkable, the disease having advanced apparently to its last stage and involved large masses of neighboring glands, so that the operation was performed under the most unfavorable circumstances. In these cases, however, the persons operated on have lived since the local extir- pation of the disease up to this time, that is, from nine to twenty years, in perfect health.! While thus it is contended that there is no growth which may not be malignant, and none which may not be innocent in the sense inferred, it is not denied that some growths have a greater tendency to spread and affect the system than others. In reference to treatment, therefore, it becomes of the greatest importance to determine the laws which ap- parently govern the propagation and multiplication of different morbid growths, or the circumstances which render—say carcinoma and epithe- lioma—more susceptible of being communicated to neighboring and internal organs, than purely fibrous or osseous growths. There is one circumstance in reference to the removal of tumors which is frequently overlooked by surgeons, viz., that certain growths, abounding in cells, have a great disposition to infiltrate themselves among muscles and neighboring parts, and may be detected there by the micro- scope, although invisible to the naked eye. In one case I found numerous granules and commencing cells in the muscles of the tongue below an epithelial ulcer, though it seemed healthy (Fig. 232); and in the sterno- mastoid muscle, covering a tumor of the parotid gland, clumps of nuclei * Cancerous and Cancroid Growths, p. 233. f Velpeau, Traite des Maladies du Sein, etc., 1854; and 2d edition, 1858, in the preface to which are enumerated, p. xxx, no less than 26 cases which up to the close o ' that year remained well. See also note at the conclusion of this article. 240 PRINCIPLES OF MEDICINE. Fig. 303. that in many cases where the surgeon thinks he has removed a morbid growth, he really leaves multitudes of germs behind which continue to propagate the disease. Dr. Handyside removed the inferior extremity of a boy at the hip joint, in June 1843, for cancer of the femur. I carefully examined a small portion of one of the upper flaps, which was subsequently cut away, on observing a piece of the tumor attached to it, and found all the muscles fatty and infiltrated with young cancer cells (Fig. 304). In short, all the muscles which formed both flaps were already cancerous, and I told the operator that the disease would probably return in the stump. The incisions healed * Cancerous and Cancroid Growths, p. 103. Fig. 303. Fibre of the sterno-mastoid muscle, in the neighborhood of a cancerous growth, partly transformed into fibres, with masses of young cancer-cells. Thia figure, published by me fifteen years ago, exhibits all the facts subsequently seen by the so-called cell pathologists. I need scarcely point out to the experienced observer how an imaginative histologist, when copying such an appearance, might—by strengthening the outlines of those fibres which surround the groups of nuclei—make the whole resemble endogenous cell growth. Fig. 304. Fasciculi of muscle, forming the flap in an amputation of the thigh, already infiltrated with young cancer cells, a, The latter, after the addition of acetic acid. Fig. 305. Granules, nuclei, and granule cells, infiltrated among the tubes of the brachial nerve, near a cancerous growth. 250 diam. PROPAGATION OF MORBID GROWTHS. 241 (Fig. 232, 303). I have found the brachial nerve in connection with a cancerous tumor of the humerus, infiltrated with granular masses and granules, some of these latter arranged in rows, and meeting together, apparently to form nuclei of new cells, as in Fig. 305. Professor Van der Kolk of Utrecht has confirmed these observations, and also traced incipient cancer-cells among the tubes of neighboring nerves. Hence one of the chief modes of propagation of morbid growths, is that the cells in the process of development become infiltrated among neighboring tissues. But how do they accomplish this ? Van der Kolk suggests that the fluids which they contain mingle with the juice of the parenchymatous substance around them, and that in the latter there are deposited molecules and granules, which, having received from the former certain tendencies to evolution, are ultimately transformed into similar structures. This view is not only exceedingly ingenious but very probable, and will serve to explain how the blood and distant organs arc secondarily affected. The notion of solid germs floating in the blood has no facts in its support, but the idea of a fluid secreted by cells being absorbed is consonant with every known law of nutrition. The molecules in the fluid, then, of a morbid growth, formed during its development, as the result of cell or other formation, would seem to be the most probable material producing secondary growths. We have seen that many tumors which have no cells, may be recurrent and attack tissues secondarily. Still they all contain a parenchymatous molecular juice, and as a general rule those that are most soft and pulpy are most liable to return. I have recorded two singular examples of cancroid growths which returned and proved fatal. In one of these, the tumor was removed from the breast by Mr. Page of Carlisle, and consisted of a pulpy fibrous substance, in various stages of development, and of granular cells. Six months afterwards a similar growth of like structure formed in both thighs, of which the patient died (Figs. 306 to 308). In another case the leg was amputated above the knee by Mr. Norman of Bath, for a fungoid tumor, below the gastrocnemius muscle. It consisted of fusiform corpuscles in different stages of development, mingled with naked nuclei, a multitude of molecules and granules, as represented in the figure (Fig. 309). Two years later a similar tumor formed in the right chest, which compressed the lung, and caused death. These, together with the cases of sarcoma, neuroma, enchondroma, Fig. 306. Structure of the soft part of the tumor removed by Mr. Page of Carlisle. Figs. 307 and 308. Structure of the more indurated parts. 250 diam. 10 242 PRINCIPLES OF MEDICINE. Fig. 3u9. Fig. 310. just as correctly talk of a rheumatism being innocent or malignant, as apply those terms in different cases to fibrous, cartilaginous, osseous, or other kinds of morbid growth, for no other reason than because sometimes they are localised in a part, and at others are more general.* Decline or Degeneration of Morbid Growths.—In their decline, as in their development, the various kinds of morbid growths follow the laws which regulate degeneration of texture. Some, as lipoma and adenoma, have been known to be gradually absorbed and disappear. Others undergo the albuminous, fatty, mineral, or pigmentary transformations, to be subsequently described. To enter into the peculiarities of each morbid growth in this respect would lead me too far. They will be referred to generally afterwards. All I need say here is, that every kind of morbid growth may degenerate and prove abortive in one way or another. Cancer even has been known to slough out, and heal by cicatrix, besides having been checked in its development and rendered abortive in every known mode of retrograde transformation. (See Morbid Degenerations of Texture). General Treatment of Morbid Growths. The treatment of morbid growths may be divided into local and constitutional. The local treatment comprehends—1st, Means of re- tardation and resolution. 2d, Means of extirpation. * The facts to which I have alluded, and others of a like kind that are daily occur- ring, have induced M. Velpeau, in the second edition of his work on diseases of the breast (1858), to speak as follows—" J'ai dit plus haut que, sans avoir de conviction absolue sur les transformations oancereuses, j'etais loin, cependant, d'etre aussi decide qu^autrefois dans le sens negatif. Les faits, en se multipliant dans ma pratique, ont fini par ebranler mes croyances et meme par me faire pencher, sous ce rapport, vers la doctrine affirmative deiendue avec talent en dernier lieu per M. Bennett d'Edim- bourg." He adds, much to his honor, " Renoncer ainsi h ses anciennes doctrines, juste au moment oil les autres savants, oii la jeunesse active et laborieuse s'en em- parent et les soutiennent avec ardeur, peut etre penible sans doute, mais les besoins de la verite doivent passer avant tout!" Fig. 309. Structure of a fungoid growth of the leg, removed by Mr. Norman of Bath. Fig. 310. The same, after the addition of acetic acid, 250 diam. GENERAL TREATMENT OF MORBID GROWTHS. 243 1. Means of Retardation and Resolution.—These consist in applying all those means which are opposed to development of tissue, such as topical cold and graduated pressure, avoiding moist applications and local irritation. Such means, as they are opposed to those circumstances which are known to favor cell growth in the animal and vegetable worlds, such as heat, moisture, stimulants, and room for expansion, might be expected to retard the progress of morbid growths. Dr. James Arnot has in consequence found much benefit from the application of frigorific mixtures, and Dr. Niel Arnot has applied graduated pressure with occasional good effect. The difficulty of such treatment consists in the frequent impracticability of their application, as they can only be serviceable when the growth is situated externally, and on particular parts of the body. Such treatment also is counteracted by the fact, that although you may freeze the external parts, the growth is continually supplied with warm blood from within; and that when you compress outside, you thereby run the risk of causing extension towards the interior. Both these means, however, which may be carried on con- jointly, are eminently deserving further trial. As moisture favors, so dryness is opposed to growth, and the avoidance of local irritations, as they are a common exciting cause, is obviously indicated. 2. Means of Extirpation.—These are excision of the part, and the application of chemical agents which destroy texture. From all that we have said as to the origin, mode of development, and propagation of morbid growths, it would appear that they may all destroy life, and that those which exhibit the most rapid powers of spreading may supervene on the more indolent ones. Hence, as a general rule, so soon as it becomes evident that means of retardation and resolution have failed to arrest their progress, an operation should be had recourse to. If early excision were more practised, many of the lament- able cases which occur in practice would not arise. Should the cancerous growth even be advanced, it should never be neglected so long as the diseased parts are external and within the reach of the knife. We have also seen that surgeons, in removing the tumors, have left un- touched tissues infiltrated with cells capable of causing their regeneration. Hence the neighboring textures should be carefully scrutinised, and all those portions of them infiltrated with cancerous germs carefully removed. For this purpose the microscope ought to be a necessary instrument in the operating theatre, and every suspected tissue in the neighborhood examined by experienced histologists, before the lips of the wound are closed. This proceeding, which I recommended in 1849, has not, so far as I am aware, yet been practised by surgeons, but its propriety has since then been supported by Van der Kolk, and it will yet, I believe, become generally practised, when a knowledge of the pathology of morbid growths is better understood. The practice of M. Girouard of Chartres, who by caustic directed towards the neighboring tissues around cancers, has sought to destroy the germs whereby they spread, and thus prevent return of the growth, is, in this point of view, highly encouraging.* * Archiv. Gen. de Med., torn. xcv. p. 739. 244 PRINCIPLES OF MEDICINE. The application of chemical means, as various kinds of escharotics, to destroy local growth, has been extensively tried, but without as yet having enabled practitioners to arrive at any definite results. The great obstacle is the impossibility of attacking the entire growth; and if this is not always performed by excision, still less frequently is it accom- plished by escharotics. Of late years an opinion has prevailed that this mode of treatment deserves further trial.* M. Velpeau speaks favorably of sulphuric acid mixed with saffron; and Mr. Syme has proposed saw- dust as a cheaper material than saffron, whilst its action is confined superficially by a wall of gutta percha made to adhere to the skin.! By such an escharotic the whole morbid growth, it is said, may be destroyed at once. The immediate pain is prevented by bringing the patient under the influence of chloroform, the slough is subsequently poulticed until it separates, and then the granulating surface allowed to heal. Great discussion has occurred as to the value of the chloride of zinc, applied by vertical scorings or slight incisions, so that it shall gradually perco- late through the entire growth. This mode of proceeding takes from three to seven weeks,:}: but is effectual in removing the tumor, as all those who have examined the preparations in the Middlesex Hospital, and such as have been removed by the same method of alternate incision and application of caustic by Mr. Moullin of London, may easily satisfy themselves.^ M. Maisonneuve has employed Canquoin's paste, composed of the chloride of zinc, 1 part; wheat flour, 3 parts; mixed up with a suffi- cient quantity of water. This is formed into arrow-shaped heads, dried and thrust into or around the tumor, according to circumstances. || Other chemical agents have been proposed, but the experience acquired of these methods, and especially of their ultimate good effects, is as yet so limited as to preclude the possibility of forming a just estimate as to their merits. Constitutional Treatment.—We are altogether unacquainted with any means of counteracting the tendency which predisposes to morbid growths. But considering that for the most part the constitutional change is con- nected with excess of nutrition, and in this respect is altogether opposed to what we observe in cases of scrofula and tubercle, we may infer that lowering the nutritive processes, while we yet allow the general tissues to be supported, should be the rule of practice. In carcinoma, and rapidly formed growths, the body (unless it produce emaciation by at- tacking the chylopoietic viscera) is for the most part fatty, and a diminu- tion of this element in the food should be aimed at. But at a later period, when exhaustion makes its appearance, nutrients and stimulants will be required to prolong life. Note.—It i8 impossible to over-estimate the services which have been rendered to science by M. Velpeau, from carefully watching the results of those operations he * Langston Parker, on the treatment of Cancerous disease by Caustics, 1856. ! Edinburgh Medical Journal, November 1857. ± Report of the Surgical Staff of the Middlesex Hospital, etc., 1857. § I have myself been able to do this through the kindness of Drs. Van der Byl and Handfield Jones. J Journal of Practical Medicine and Surgery, March 1858, p. 485. MORBID DEGENERATIONS OF TEXTURE. 245 has performed, where the tumor extirpated has been microscopically examined. At a time when some surgeons were sneering at histological research, he applied to MM. Lebert, Follin, and Robin, and obtained careful microscopical exammations of the tumo rs he removed. The result now is, that we have the most positive proof that cancerous growths may be successfully removed by the surgeon, and the individual still survive in perfect health, for periods varying from six to twenty years. Had the microscopic examination not been made, we should still have remained in doubt as to the true character of the tumor. But the following extract from a letter I received from M. Velpeau last October can leave no doubt in the minds of the most sckeptical. The references are to the pages in the first edition of his work on the Diseases of the Breast, where the cases will be found detailed at length. 54 Rue de Grenelle St. Germain, October 19th, 1864. " I can now inform you that the Demoiselle D. (p. 584), operated upon nearly twenty years ago, and at present eighty years of age, remains cured and in excellent health. It is the same with Madame D. (p. 584), operated on in 1847, with Mme. G. (p. 594), with Madme. L. (p. 596), operated upon twenty-eight years ago, and who are still living. Mesdames V. (p. 684), H. (p. 686), L'h. (p. 608), and the man referred to, p. 499, still live, and have had no return of the disease."—" To my former list I could now add 991 cases. I would especially refer to that of Madame de la Vie...., who was operated on six years ago, for a lardaceous encephaloid, perfectly charac- terized, occupying the left breast. This lady, tolerably stout and otherwise strong, now possesses the most excellent health. It is the same with Madame de Mon...., but the most extraordinary case is the following:—A lady B., who has been operated on nine times for a fungoid encephaloma of the right breast (four times by caustic, five times by the knife) under the same conditions as Mme. H. (p. 686), has now un- dergone a permanent cure. All these operations were practised during five years. After each of them the general health improved for some months. Then the growth re-appeared, and it wa"s necessary to commence once more. On the last occasion, it was necessary to penetrate to the ribs, and cauterize the surface. The wound not- withstanding at length cicatrised, and the former large excavation, occupying the whole side of the thorax in this courageous lady, is now solidly healed. She has re- covered her embonpoint, and suffers in no way, and enjoys a health that leaves nothing to be desired. Everything went through the same course as occurred in the case of Madme. H. (p. 686)." " Such is the information in my power to give you, begging you to observe that in all these cases, as in all those to which I give the name of cancer, every precaution, whether clinical or anatomical, was employed, and the diagnosis established by direct observation, careful dissection, and microscopical research." It results from these facts that the views long maintained by the author, as to the possibility of permanently eradicating cancer, may now be considered to have been incontestibly demonstrated. MOKBID DEGENERATIONS OF TEXTURE. In the same manner that there may be hypertrophy or increase, so there may be, although from exactly opposite causes, atrophy or diminu- tion of texture. Atrophy may consist in simple decrease of bulk, the organ or tissue otherwise retaining its usual structure and function. There may be less work to do, and less force consequently required; and for the same reason that the legs of a dancer become larger, those of a 246 PRINCIPLES OF medicine. bed-ridden individual become smaller. So also as there may be increased bulk with alteration of texture, so there may be diminished size with change of tissue. These latter atrophies, as they constitute true organic diseases, especially merit our attention; and they may be arranged in four groups, viz.—1st, Albuminous; 2d, Fatty; 3d, Pigmentary; and 4th, Mineral Degenerations. Albuminous Degeneration. We have already seen how essential albumen is to nutrition: and that to be made assimilable in various forms to the tissues of the body, it must be subjected to certain processes. Under other circumstances it may be effused, or collect in particular parts of the system, constituting organic diseases. If transuded through the vessels in a fluid form, that is, dissolved in water, as we find it in the serum of the blood, it produces what is called dropsy. If precipitated from its solution in a solid form, it may constitute a variety of inorganizable deposits presenting various kinds of ultimate structure. Lastly, tissues composed of various proxi- mate principles may be wholly converted into an albuminous substance, and thereby have their vital properties impaired or lost. We shall notice these shortly in succession. Albumen in solution is frequently effused from the blood-vessels as serum, constituting dropsy. It is distinguished from an exudation by containing no fibrin. There is not, therefore, that disposition to rapid coagulation and formation of an organized blastema, although there is often a precipitation of matter, capable of assuming various forms. We have seen that an exudation depends on an alteration of the vital force Fig. 811. which governs the attraction and selection of nutritive materials from the blood. Serous effusion or dropsy, on the other hand, is always indicative of mechanical obstruction to the return of blood from the capillaries Fig. 311. Structureless membrane formed by heating the clear fluid of pemphigus. On the left hand the membrane is folded together.—(Wedl). 800 diam. ALBUMINOUS DEGENERATION. 247 through the veins. Thus, pressure of a tumor on the large venous trunks, disease of the heart and liver rendering the circulation difficult, or of the kidneys and skin diminishing the secretion or exhalation of fluid, are its most common precursors. In Bright's disease of the kid- ney, conjoined with various changes in the texture of the organ, serum containing albumen passes off in the urine. Membranous Albumen.—Albumen in solution, if it exists in tolerable quantity, is very apt to be precipitated in flakes or membranes. At the onset of vesicular diseases, as pemphigus, the ^ fluid effused has been observed on being heated to contain smooth or folded laminae (Fig. 311). The same laminae may be pro- duced artificially by bringing oil or chloro- form in contact with serum. Hence they are not fibrinous but albuminous. The mere shaking of white of egg, or manipulating serum in various ways, will often cause these laminae to form and constitute shreds, which resemble fibres, but are truly membranous (Panum, Melsens). Sometimes such mem- branes, if produced slowly, collect round a central nucleus and ultimately form a concre- tion. The same has been observed by Wedl in the scrotum, where the skin has been con- Fig- 31'2- verted into a tough substance like caoutchouc (Fig 312). The concen- tric laminae which form in the interior of aneurisms present a similar structure and are probably albuminous. (See Concretions.) Fibroid Albumen.—Many tissues, especially fibrous ones, when ex- posed to a certain amount of pressure, become unusually dense. This may be the result of an exudation, which undergoes a peculiar transfor- mation, the whole becoming white in color, hard and tough to the feel, and consists of dense fine fibrous texture. It may also be the result of a peculiar transformation, or fibrillation of pre-existing tissues, inde- pendent of exudation. It has been described by Dr. Handfield Jones under the name of fibroid degeneration. We find it in various situa- tions—1st, in the areolar texture of the skin, producing peculiar indu- rations, as in the hide-bound integument of infants. 2d, On serous membranes, where it occasions opaque thickenings, as in the arachnoid, pleura, peritoneum, and pericardium. The white spots in or upon the pericardium covering the heart are of this character, and all of them have their probable origin in a chronic form of exudation, which is subsequently transformed into a white albuminous mass (Fig. 171). The thickened valves of the heart, and especially the rough indurated masses occupying their free margins, are also examples of this lesion. 3d, In mucous membranes the areolar tissue between the basement membrane and muscular coat, and even the non-voluntary muscular substance itself, is very liable to undergo thickening and induration. Fig. 312. Edges of albuminous laminse, in a case of hydrocele, where the skin was destroyed, a, Edges of horizontal laminae; b, the same in another place, with brownish-yellow pigment granules.—(Wedl.) 250 diam. 248 PRINCIPLES OF MEDICINE. Fig. 314. tion. We have seen the stomach and bladder upwards of an inch thick from this cause (Fig. 313). 4th, In the areolar texture of parenchymatous , j organs, as in the liver, kidneys, lungs, etc., J'it constitutes the lesion denominated cirrho- sis, which consists of dense fibrous deposits, and causes atrophy of the glandular sub- stance. (See Cirrhosis.) Dr. Handfield Jones considers the white fibrous tumors ef the uterus to belong to the same class of mor- bid alteration, which they no doubt do, as also similar formations in the placenta, spleen, and other organs. This form of degeneration gradually passes into, and may be identical with fibrous growth, as the result of exuda- 5th, The remarkable change which takes place in cartilage belongs to this head, and has been ably described by Redfern. Under the in- fluence of a stimulus, vital or mechanical, the cells enlarge and their in- cluded nuclei multiply, and the previously hyaline inter-cellular substance fibrillates and becomes transformed into bundles of fibres (Fig. 269, 270). Celloid Albumen.—Cell-walls are generally of an albuminous character, but between them and the nucleus there exists for the most part a fluid, so that interchanges are constantly going on between the three essential portions of the cell, whereby its growth is kept up, and in many cases development carried on. It fre- quently happens, however, that even in formative fluids, albumen is thrown down in globular masses, so as to resemble cells. Thus, 1st, In pus, soft cancer, and other forms of morbid growth, there may frequently be seen diaphanous bodies floating iibout, of various sizes, of extreme delicacy, and perfectly globular in shape. Very commonly they are homogeneous and perfectly transparent, but sometimes they Fig. 315. FiS. 317. contain one or more bright refracting granules, and at others a cavity seems to have formed in the inte- rior, but no nucleus (Fig. 315). 2d, Pus corpuscles (Fig. 68) and collections of blood globules may frequently be seen sur- rounded by a similar diaphanous coating more or less thick In recent hsemor- rhagic apoplexies in man, I have seen collections of blood corpuscles, sur- Fig. 313. Dense fibrous structure, with naked nuclei from thickened and indurated coats of the stomach. Fig. 314. The same after the addition of acetic acid. Fig. 315. Diaphanous albuminous bodies, with fatty cancer cells from the c.;a- phragm. Fig. 316. Groups of blood corpuscles from an apoplectic extravasation in tl.c human brain, surrounded by an albuminous layer. Fig. 317. A similar albuminous layer, round groups of blood-cells from the brain of a pigeon. 250 diam. ALBUMINOUS DEGENERATION. 249 rounded as if by a cell-wall (Fig. 316,) and Dr. J. B. Sanderson has pro- duced them artificially in pigeons, by pricking the brain through the cranium with needles, and caus- _ /^===!»^ /"*% r\ ing extravasation of blood. A =========_= v_^^^^ V_^/ ^s^ fow days after such an experi- ment, groups of oval corpuscles may be found surrounded by a layer of albumen, often presenting a series of concentric rings* (Fig. 317). There can be no doubt that in these cases an albuminous precipitate is formed round the blood corpuscles, which are beginning to break down and decay. 3d, Another form of celloid albumen may be seen in certain mechanical softenings of the brain and spinal cord, where the nerve-tubes break up, unite at their edges, and form globules bounded by double lines. I have seen them pro- duced under the microscope by mechanical pressure between glasses, in the manner represented in the figure (Fig. 318.) Molecular Albumen.—Some textures assume a peculiar kind of in- duration, which on examination, is found to consist of molecular amor- phous matter. 1st, Induration of the brain consists of an albuminous molecular matter deposited among the tubes, rendering the thinnest sections opaque, and giving to the texture a peculiar toughness. This induration is common around chronic abscesses of that organ, and may have originated in exudation, which has been transformed into the sub- stance described. 2d, Certain peculiar yellow masses, found in the kid- ney and spleen, with abrupt margins of irregular outline, appear to me to constitute a degeneration of a similar character. 3d, Certain forms of tubercle may be said to consist of the same amorphous, finely mole- cular albuminous substance. Waxy Degeneration.—A peculiar change in the pre-existing texture of various organs, known under this appellation, sometimes called brawny or bacony, as in the case of the liver and spleen, appears to me to be a form of albuminous degeneration. 1st, The liver when thus altered presents to the naked eye a pale fawn color, its tissue is of unusual density, and its section presents a smooth surface, with semi-transparent edges. The hepatic cells under the microscope are seen to be shrivelled, colorless, and of peculiar transparency, with the nucleus absent, or evidently disappearing (Fig. found similarly affected to those in the liver, ''""$&) and the Malpighian bodies not unfrequently " undergo the same alteration. (See Diseases of the Kidney.) 3d, In the spleen the same characters are presented, both to the naked eye and under the microscope, the cells of the parenchyma, * Monthly Journal of Medical Science, September and December 1851. Fig. 318. Substance of nerve-tube, by means of traction, broken across and form- ing two globules, with double outline. Fig. 319. Cells of the liver, in waxy degeneration of that organ. 250 diam. 250 PRINCIPLES OF MEDICINE. as well as those in the Malpighian bodies, being compressed together, shrivelled, and presenting a similar pale, translucent appearance. 4th, In the intestinal mucous membrane it is by no means unfrequent, com- municating to it a peculiarly blanched and thin appearance. Under the microscope the villi, vessels, and epithelial cells in various degrees, may be seen to have undergone this peculiar degeneration. 5th, I have seen the same transformation in the placenta, as well as in simple chronic, . cancerous, and tubercular exudations. By others it has been seen in bone, and there is no reason why it may not affect almost every organ and tissue of the body. It is evidently, as an albuminous, as widespread in its extent as the fatty degeneration. This lesion has received various names, having been denominated " lardaceous degeneration " by Abercrombie, and rightly considered albu- minous in its nature by Hodgken, Bright, and Rokitanski. By Budd, it was regarded as scrofulous. The term waxy degeneration is evidently the best, derived from its resemblance in the kidney and liver to bees- wax. Under the microscope also it resembles in its translucency color- less wax or spermaceti. The term amyloid degeneration, recently employed to designate this lesion by Virchow and his followers, is not only vicious but productive of the greatest confusion. This term means resembling starch, and has been used by me to designate rounded soft mineral bodies, frequently found in the brain and in cerebral tumors (Fig. 392), and which in structure resemble starch. It has also been applied by Carter to starch- like bodies found in various tissues; and more recently by Bernard, Pavy, and others, to the substance obtained from the liver, and which is readily transformed into sugar. In both these latter cases, there is a chemical relation to the substance of starch, as seen by the actions of re-agents. But the waxy degeneration has no relation to starch whatever. I have never seen it transformed blue by iodine, either with or without sul- phuric acid, but only into a brownish or purple red, which is the color of iodine itself. The truth is, I have found that this albuminoid degen- eration has the property of fixing certain colors, like the nuclei of the textures; so that not only when steeped in iodine is it deeply tinged as compared with the surrounding textures, but the same thing occurs when it is exposed to the action of carmine and indigo in solution. This degeneration was first carefully examined by me, microscopically, in 1845, in the case of Margaret Clark (see Phthisis), when the peculiar translucency and degeneration of the hepatic cells was observed and care- fully figured. It was demonstrated and described at that time and since to all my pathological and clinical classes in Edinburgh. In April 1853, some of these figures were published, in No. VIII. of the first edition of this work (Fig. 319). On the 17th of December 1853, I brought the subject before the Physiological Society of Edinburgh in a verbal communication, which is very imperfectly reported, but in which the announcement was made that, in the specimens of spleen, liver, and kidney then on the table, I was " satisfied from numerous observations, that it was a primary alteration of the cells, and though frequently associated with fatty degeneration, was not essentially connected with it."* * Monthly Journal, February 1854, p. 186. ALBUMINOUS DEGENERATION. 251 These views I have ever since maintained and taught in this school, and never failed to point out the fundamental error of Virchow and his fol- lowers, who associate it with starch, and call it amyloid. The clinical history of the waxy degeneration has yet, for the most part, to be studied; but observations I have made tend to convince me that it may often be diagnosed in the living body with certainty. It is the frequent cause of persistent diarrhoea in leucocythemia, and of a peculiar form of albuminuria, afterwards to be noticed (see Diseases of the Kidney). This lesion is not unfrequently associated with the fatty degenera- tion next to be spoken of, especially in the liver and kidney, when in a cirrhosed state. (See Fig. of Cirrhosed Liver.) It would appear from analyses of the liver, mostly made by Dr. Drummond, and collected by Dr. W. Gairdner,* that the human liver, when affected with the waxy degeneration, contains less water, considerably less fat, and a greater amount of solid constituents than natural. Colloid Degeneration.—We have previously seen that there is a peculiar form of cancer called colloid, in which glue-like matter is asso- Fig. 320. Fig. 321. ciated with cancer cells. But colloid occurs independently of cancer, constituting the sole contents of certain cysts (see Cystoma). It would appear to vary in chemical composition, as I have observed that speci- mens of it sometimes coagulate into a solid mass, whilst at others they are unaffected by the action of spirits. If not identical, it is at least allied to the albuminous degeneration. The enlargement of the thyroid gland in bronchocele, and the contents of compound ovarian cysts, are generally owing to the formation of colloid matter (Fig. 320). Not unfrequently colloid masses become indurated, and assume a radiating striated appearance (Fig. 321). * Monthly Journal of Medical Science, May 1854. Fig 320. Section of the thyroid body, with some of its glandular sacs, distended with colloid matter.—{Kolliker.) Fig. 321. Radiated colloid masses from a cyst in an atrophied kidney, a, Lines radiating from a central point: b, radiated mass surrounded with a clear border; c, radiated mass with a central granular substance and radiated border c'; d, the same with an external clear border; '<> w*,g exudations, and extravasations of blood, present- >s ing a milky, yellow, or fawn-colored hue; or in the blood, urine, and other fluids, giving them a chylous character. Indeed, the presence of fatty molecules may be said to be almost constant in morbid products; and, when collected together in masses, they constitute organic lesions of the greatest gravity. Fatty Degeneration of Cells.—It was shown by Bernhardt, that all kinds of cell formation, under certain circumstances, undergo the fatty degeneration. The manner in which this is accomplished is in all cases the same. A few fatty molecules first form between the nucleus and cell-wall. These increase in number, and some of them apparently are fused together to produce larger ones. This process goes on until at length the whole contents of the cell consist of fatty molecules and a bed e / g Fig. 323. granules. The nucleus is now no longer visible, and in many cases wastes away, as if from pressure. Occasionally, this fatty deposition of Fig. 322. Fatty molecules in groups, from the opalescent or white opaque centres of large colloid masses in the ovary. Fig. 323. Granular corpuscles and masses from cerebral softening, a, Nucleated cell with a few granules; b, granules within the cell, partly obscuring the nucleus; c, granules over the nucleus; d, granules within the cell, no nucleus visible; e, cell nearly filled with granules; /, cell completely filled with granules ; g, cell contracted in its middle; h, granular mass, the cell-wall having dissolved; i and k, granular masses peeled off from the vessels. 254 PRINCIPLES OF MEDICINE. molecules takes place within the nucleus in the first instance (Fig. 323.) In either case the cell-wall, distended by the accumulation of fatty particles, at length gives way, and the included oil granules either abed e separate, or for a time adhere together 8 , to move; 7ra0o9, disease.) Rest.—In the economy of the organized world, we especially observe that periods of activity alternate with periods of repose. This depends upon the circumstance that action produces waste of tissue, and hence the necessity of pause in action, in order that substance may be added. All growth and secretion seem to proceed by a succession of actions and pauses. The movements of the heart, which appears to be continually beating, really consist of contractions, relaxations, and pauses, which followeach other in regular order. The functions of the nervous system follow the same law. After exercising the powers of thought, after the reception of sensations or the performance of voluntary motion for any time, we are not only disposed, but are imperatively obliged, to submit to their suspension for a certain period. This state of suspension is sleep.. On awaking we feel refreshed,—new strength is imparted to the muscles, higher sensibility to the nerves, and greater power to the mind. Now, disease is also a state of action, and more especially predisposes to waste of tissue, so that not only is exercise opposed, but rest is conducive, to recovery. Nothing so rapidly exhausts the body as a high fever. To Mr. Hilton we are indebted for an excellent work, entitled, " On the Influence of Mechanical and Physiological Rest in the Treatment of Accidents and Surgical Diseases," etc., the perusal of which I strongly recommend to you; therein, also, he alludes to the diagnostic value of pain. I believe a very interesting chapter might also be written on the therapeutical value of pain, which, in many cases, by constraining the individual to keep motionless, thereby provides for that rest so necessary for recovery. But the principle or rule treated of by Mr. Hilton as a surgeon, admits of equally wide application in medical practice. In- ternal organs, when diseased, should for the most part not be called into action. Sometimes, however, this is necessary; when, for example, in order to remove mechanical obstruction, we must stimulate them, as in the case of constipation, or blocking up of the renal tubes. No wider error prevails among mankind than the idea that incipient disease HYGIENICA. 325 of a part being manifested, continued or increased exertion may get rid of it. Among the laboring population, as we find them in our hospitals, how often are pneumonias and other severe disorders neglected in the beginning, under the hope that they will go away ? They continue their exhausting labor, struggle against the disease as long as possible, and when at length they are obliged to yield, the morbid condition is intensified, whilst there is diminished vital force to resist the evil. Such are the worst and most tedious cases of recovery from acute affec- tions met with. On the other hand, cessation from exhausting pursuits, and immediately going to bed and remaining there, are, under similar cir- cumstances, the best aids to successful treatment. Another idea of rest should not be overlooked, viz.—that implied in giving repose to one organ l>y calling others into action, as is exemplified by the pleasure ex- cited in the minds of those employed in bodily labor or monotonous toil, by literary pursuits, or change of scene. Or, again, the refreshment and invigorating result of walking, rowing, or other muscular exertion, to those condemned to sedentary employment or long-continued mental labor. Thus it may happen that, to some men, true rest consists in digging a garden or climbing a mountain—in having a hard day's sport, or taking a long journey. Climate.—The influence of climate in therapeutics, involves the con- sideration of many circumstances connected with the physical condition of numerous localities, such as their dryness or humidity, the purity of the atmosphere, the amount of wind, equability or changes in temperature, the elevation or depression of the land, its geological formation, quality of the springs, nature of the vegetation, etc. etc., which cannot, from its extent, be entered upon in this place. At the same time, there can be no doubt that the production and progress of diseases are greatly in- fluenced by locality, some existing in one place, while they are absent in another. It may also be observed that particular circumstances in a locality have modified existing disorders, have banished some and intro- duced others. Thus, draining the various lochs and marshes that for- merly existed in Edinburgh, has entirely removed intermittent fever, which used to prevail, while, within the last twenty years, we have seen typhoid fever become common, which was formerly unknown. The geographical distribution of disease is a subject which has scarcely been studied medically, although the labors of Mr. Keith Johnston of this city have done much to introduce it to the notice of scientific men. The wide possessions of the British empire have made us familiar with the fatal or injurious effects upon Europeans of a residence in particular localities, more especially in the swampy plains of the East and West Indies, on the coasts, and in the interior of tropical Africa, in the more temperate regions of Australia, and in the prolonged winter and extreme cold of North America. The public and private enterprising spirit of the nation, has also led to numerous exploring expeditions in all parts of the world, which have exhibited to us under what opposing conditions of climate and surrounding circumstances man may contrive to exist. But when, in any given case, the question comes to be, to what place 326 GENERAL THERAPEUTICS. you shall send your patient in order to save or prolong his life, it must be confessed we are often puzzled by contradictory or erroneous informa- tion. When in foreign countries, the health becomes impaired from tho long excessive heat, a return home for a period is the obvious proceeding. When malaria causes fever in swampy jungles or pestiferous marshes, hastening from the spot to healthy plains or to the open sea becomes necessary. And when, in our own country, the question arises, where we shall send the consumptive patient, in order to avoid our changeable climate and cold winter winds, in winter, we naturally say, to a land where, during that portion of the year, the weather is warm and equable. On this point, I shall speak at length under the general treatment of phthisis, to which I must refer the reader, as well as to the numerous works written on climatology. Ventilation.—I believe that a proper ventilation of the rooms, and especially of the sleeping rooms, occupied by invalids is a matter of the greatest importance in treatment. The prevalent notion that coughs and colds, sore throat, and indeed most diseases, should be combated by wrapping up, confinement to close heated apartments, or to beds sur- rounded by curtains, is most injurious. A perfect oxygenation of the blood by the introduction of pure air into the lungs is not only neces- sary to healthy persons, but is especially so to those who are unhealthy. When it is considered that most persons spend one-third of their life in bed, the importance of breathing a pure air during that long period must become evident. Yet how frequently do we see families make great sacrifices to obtain what is called fresh air, by going into the country for some months or weeks every year, yet when there crowd three or four persons together in confined sleeping-rooms. They get their fresh air, it is true, in the day, but never think of avoiding foul air at night. In bronchitic and phthisical cases, the relief experienced by sleeping all night with the window slightly open at the top, is often remarkable, as was first pointed out by Dr. M 'Cormack of Belfast. On this account I have satisfied myself of the great superiority, as means of ventilation, of the sash windows in England over the windows formed of two lateral halves, opening side ways, so common on the continent. On the other hand, while securing free air, the utmost care should be taken to avoid draughts, and violent currents of wind so frequently encountered in foreign hotels, with long corridors, and doors exactly facing the windows. Although much still remains to be done notwithstanding the labors of Arnot and others in bringing about a perfect system of ventilation in English houses, they must be admitted to be more comfortable, and by means of their sash windows capable of renewing fresh air with less risk to the delicate than what exists elsewhere. In Italy, where the climate is so fine, the houses are too often unbearable. Heat and Cold.—The influence of the atmospheric temperature belongs essentially to climate. Here, I shall only refer to the therapeutic effects of heat and cold applied locally. In this respect they operate in three ways—1st, As stimulating or retarding growth; 2d, As alleviating pain; and, 3d, As a nervous stimulant, or sedative. An elevated temperature, HTGIENICA. 327 especially when combined with moisture, is well known to favor growth both in the vegetable and animal worlds, and thus I pointed out many years ago—(Treatise on Inflammation)—is to be explained how warm poultices favor suppuration, that is, the growth of pus cells. On the other hand, cold and a low temperature are opposed to growth, and act as astringents, and hence why their application immediately after the receipt of blows or injuries restrains inflam- matory action, and checks exudation and its subsequent development. The immediate good effect of cold water applied to the eye, when it has been irritated by dust or sand, is a good example of the therapeutic action of cold. The influence of cold and heat in alleviating pain is difficult to explain, especially how in some cases a diminished, and in others an elevated temperature causes so much relief. Thus some kinds of cepha- lalgia and nervous pain are at once alleviated by cold. I know of nothing that produces such immediate ease and comfort in cases of typhus fever, with headache, as gently pouring cold water over the scalp. In other cases, apparently similar, it is warmth which operates. I was summoned to a married lady who, during the day, had expe- rienced several rigors, and found her in the evening with a burning skin, rapid pulse, furred tongue, intense headache, in short, all the symptoms of fever. To alleviate the intolerable headache I poured cold water over the head, which to my surprise caused no relief what- ever. I then immediately changed the cold for hot water, and as if by magic the pain at once disappeared. This led me to suppose that, after all, the case might not be one of fever, although at the time I could obtain no information frorti the patient to satisfy my doubts. But in a week she aborted, having been unconscious that she was preg- nant. The only practical rule I know as to this matter is, if cold fails, to try warmth. Most assuredly, as alleviators of local pain they are among the most powerful means possessed by the physician. Both heat and cold in excess, by their application to the skin, may be made either stimulative or sedative. Thus the actual cautery acts as a counter-irritant, and exposure of any part of the surface to a high temperature causes redness and congestion of the part. In this manner heat excites the functions of organs, and favors the external flow of blood, as in menstruation, or after the application of leeches. In the same manner the sudden application of cold is one of the most powerful excitors of reflex action. Dashing cold water on the face or breast excites inspiration, and favors recovery from syncope or apncea. The slow and long-continued action of these same agents is sedative, the tendency to somnolence in warm weather, or in front of a good fire, and the benumbing effects of cold are well known. Dr. James Arnott has ably pointed out that congelation of parts from intense cold constitutes a means of producing insensibility in surgical operations, without the danger arising from the inhalation of narcotic vapors. Clothing.—Medical men have too frequently an opportunity of ob- serving not only how habitually' deficient or improper clothing is a cause of disease, but in satisfying themselves how under certain circum- 328 GENERAL THERAPEUTICS. stances extra clothing is often therapeutic. The carelessness of young and delicate women at balls and parties, renders it necessary to caution them as to shawls and coverings. In bronchitis a piece of flannel worn over the chest, and in rheumatism over the shoulders, have ameliorated and even removed these affections. Respirators are, in truth, extra pieces of clothing, and carrying a shawl in the hand to protect the face from wind or cold chills, is at once preventive of accessions of cough. Keeping the lower extremities warm also, when driving or riding, may prevent or check disease. Rathing.—From the earliest times bathing has been employed as conducive to health, as a means of cleanliness and as securing the proper action of the skin. In recent times it has been more attended to than ever, and even raised into a special system of treatment for almost every malady, under the name of hydropathy. This, however, also includes attention to dietetic rules, exercise, and even medication when necessary, in consequence of which any good effects produced by the system are often attributable to a variety of circumstances not comprised in the meaning of the name it bears. The skin is not an absorbing membrane, and it has been proved by experiment that long immersion of the body in water causes a very trifling addition to its weight. Even with the aid of friction, medicines diffused in grease or oil enter only in minute quantities. The constant application of water to the cutaneous surface, however, care being taken to prevent dryness by a layer of oil-silk, or gutta percha, is emollient, removes irritations, favors the natural secre- tions of the texture, and is highly conducive to slow and perfect healing by granulations, as shown in what is now called the water-dressing of sores. For this reason in 1849 * I introduced this method of treating vesicular and pustular eruptions of the skin, which I have successfully practised ever since. (See Treatment of Skin Diseases). Warm Baths combine with the effects of water those of warmth, and are highly emollient, soothing to the nervous system, and relaxant. They are taken advantage of to relieve muscular spasm and rigidity, as in the convulsions of children and strangulated hernias of adults. Cold Bath, on the other hand, if used for a short time, are tonic and astringent, pro- ducing reaction and warmth of the body,'but if too long continued, occa- sion all the bad effects of prolonged cold, continued pain, feebleness of pulse and coma. The exercise of swimming in cold water would, to a certain extent, counteract these effects. Affusion—the shotcer bath, the douche, and washes of various kinds, whether warm, cold, or tepid, are other modes of bathing the surface generally or topically. Mineral Baths—these, like mineral waters, have been greatly extolled, but there are grave doubts whether any salt of an earth or a metal can, to any extent, enter the body in this way, and the same may be said of medi- cated baths. Locally, these latter baths may be useful, as in the case of the alkaline bath, which, in certain skin diseases, is directly curative by its superior emollient properties. Vapor Baths have long been em- ployed as sudorifics, and the bath in chambers of heated air called the Turkish bath, has recently been extensively introduced among us. This * Monthly Journal of Medical Science. August 1849. HYGIENICA. 329 also, after producing perspiration, is combined with friction, shampooing, the tepid and cold douche in a variety of forms. The therapeutical ad- vantages of these baths have yet to be determined. Oil, mud, and numerous other kinds of baths, have been employed in special cases, as well as the electro-chemical bath, by which it has been pretended that mercury, lead, and other metallic poisons may be drawn out of the body. Light.—The remarkable stimulating effect of solar light to the animal and vegetable worlds must also, under certain circumstances, be thera- peutical. It is difficult to estimate this, although its exhilarating influ- ence may often be observed in sick persons. On the other hand, dark- ness is advisable in acute affections of the eye, and in cases of mental irritation. It is also favorable to sleep, and depression of the vital powers. Death most frequently occurs during the night. I was much struck when examining the private asylum of Messrs. Falret and Voisin, some years ago, near Paris, to observe how carefully their melancholic cases were placed in light rooms, with brilliant-colored papers, and that the private garden outside was blooming with the gayest flowers, whereas the maniacal and excitable cases inhabited sombre apartments, while the garden outside was furnished only with dark evergreens. Electricity.—The living tissues of the body are saturated with saline fluids, whereby the operations of static, galvanic, and electro-magnetic currents easily reach them, producing two orders of phenomena—viz., 1st, chemically decomposing or destructive; and 2d, alterative or stimulant. In the latter case the peculiar property of each texture is excited by action on its molecular constituents. The sensible effects of electricity, how- ever, are greatly modified by the mode of its application. That is to say, whether the individual subjected to it, be or be not insulated—whether the form of application be that of sparks, shocks, aura, or current—the shape and nature of the electrodes employed—whether the current be continuous, interrupted, or reversed; its direction, amount, duration, and how introduced or drawn from the economy. Though electricity has been employed empirically in a great variety of diseases since the year 1745, when its accumulation within the Leyden jar was first known, we are still deficient in such exact observations as will positively determine its therapeutical value. It would appear, however, to be most useful in the various forms of nervous and muscular paralysis, neuralgia, and different kinds of spasm and convulsion. One of the most interesting facts which the experiments of John Reid demonstrated was, that in cases of muscular paralysis from injury to the nervous system, the muscles will, if left to themselves, become atrophied in a certain time, and lose their contractility; but if from time to time they be galvanised so as to contract, they will remain contractile and well nourished for months. Hence the importance, in cases of paralysis, of calling the limbs into action from time to time ; and hence the therapeutic effects of electricity in such cases. It is important, however, in applying this agent, to re- member that what is required is its stimulating, and not its exhaustive influence; and that as the former, if too long continued, produces the latter, so action thus occasioned must be carefully proportioned to the 330 GENERAL THERAPEUTICS. muscular strength and general health. This has not been sufficiently at- tended to. Many persons have been subjected so long to the influence of an interrupted current that increased weakness rather than vigor has been the result. The proper use of electricity in any of its forms, galvanic or galvano- magnetic, requires not only a profound knowledge of the natural laws regarding it, but of anatomy and physiology. If applied locally to the muscles, their origin and insertion must be well known to the operator, and if made to act through the nerves, their connection with the nervous centres, their course, anastomoses, and termination, must also be familiar to him. The brilliant researches of Metteuci, Becquerel, but more especially of Du Bois Reymond and his numerous followers, have advanced science by the discovery of many laws which regulate the electrical currents in the muscle and nerve tissues, and the relation of these laws to the vital and physical forces. Among these the following may be considered as important— A single electrical shock may last only the T-^ ^th part of a second, but the muscular shortening reaches its maximum, and returns to its former state in about one-fourth of a second. If two shocks are given, the one immediately after the muscle has returned to a state of rest, then there are two contractions. If the second stroke is given during the muscular movement caused by the first, and there is either contraction or relaxation, it causes increased shortening. But if the second stroke follow very rapidly on the first (that is, within the ^f „th of a second), the shortening is not greater than with one stroke. If several shocks are given before a muscle has time to be relaxed, it becomes hard, and permanently contracted, constituting tetanus. The less fatigued the muscle, the more rapid is the shortening. Interrupted currents or shocks of electricity therefore cause permanent or tetanic spasms in muscle, whether applied directly to itself, or indirectly through a nerve, and the intensity of this will depend on (1) the intensity and rapidity of the cur- rent ; (2) the amount, of contractile power in the muscle; and (3) the mechanical resistance the muscle may have to overcome, as from the distance or weight of parts to which it may be attached. On the other hand a continuous current of electricity only excites muscular contraction when the electrical circuit is closed or broken. In the interval it seems to flow through the tissue without causing any sensible effect. When a continuous current of electricity is caused to pass through a portion of nerve, it is thrown into a peculiar condition, which Du Bois Reymond called an electro-tonic state. If this current be sent through a portion of a nerve in the same direction as its own proper current, then the latter is increased, as may be shown by the galvanometer; but if in the opposite direction, it is diminished. Again, where the nerve comes in contact with the positive electrode, the electro-tonic state is diminished (aneletrotonus) ; where it comes in contact with the negative pole, it is increased (catelectrotonus). Between the poles, at the point where the two variations meet (point of indifference), the normal state of the nerve is preserved. Both the increased and diminished excitability of the nerves so caused bear a relation to the force and rapidity of the current. Further, the power of conduction in the nerve is diminished in the state of aneletrotonus; but on breaking the current, the con- MATERIA MEDICA. 331 ducting power returns there, while it is diminished where formerly it was in the state of catelectrotonos. Hence we can influence the con- tractions of muscles by a continuous current through the nerve, accord- ing to its force and direction. It can also be easily shown that the further from a muscle a motor nerve be irritated, the greater is its ex- citability, so that a feeble current applied to a nerve at a distance from a muscle will excite more contraction than a stronger one applied close to it. The stimulation of sensitive nerves by electricity excites their special functions, on the forming and breaking a circuit in proportion to its amount and rapidity. Hence we can excite pain through the ordi- nary sensitive nerves, flashes of light through the optic, noise through the auditory, and taste through the gustatory nerves. As with muscles also during the interval, no sensible effect is occasioned. With regard to the proper method of applying electricity in disease, great difference of opinion prevails. Duchenne strongly supports the use of an interrupted current applied locally to the muscles; while Remak maintains the importance of a strong continuous current applied to the nerves and nerve centres. Both modes of procedure require to be more generally tested by experience. In one class of cases originating in the nervous centres, as in hemiplegic paralysis, Remak's plan may be most useful; whereas in another class dependent on a primary mor- bid action affecting the muscles, as in saturnine paralysis, that of Duchenne may prove the best. It has also to be ascertained what is owing to direct and what to reflex action during the topical application of electricity. I need scarcely remark that a thorough knowledge of diagnosis should be possessed by him who undertakes the difficult task of employing so powerful, although manageable, an agent for the relief and cure of diseases. On this head medical practitioners should consult the practical works of Remak, Duchenne, Althaus, and Garratt. In concluding this short summary of what may be -considered our chief hygienical means of cure, it may be observed, that although their influences on the human economy, in its diseased as well as healthy con- ditions, cannot admit of doubt, there is scarcely any of them with which we are so thoroughly acquainted as to render their application exact in any given class of cases. On the medical applications of nearly any one of them volumes might be written, and several have been raised into sys- tems of treatment, under the names of Kenesipathy, Climatology, Hydro- pathy, Electro-pathy, etc. Their sanative influence on morbid conditions, however, as determined by a careful diagnosis, and by prolonged observa- tion as to their superiority over the natural progress of disease, is a work yet to be accomplished. In this point of view there is still open for the clinical student, favorably circumstanced, an extensive field, which, if properly cultivated, cannot but prove rich in useful therapeutical result.;. Materia Medica. By the Materia Medica we understand those agents derived from the animal, vegetable, and mineral worlds, which, forming no essential part of diet, or being necessary to life or health, are used as medicines or reme- 332 GENERAL THERAPEUTICS. dies for the relief or cure of diseases. It is to the discovery and employ- ment of these means that medical men have, for the most part, directed their energies, and, in consequence, a multitude of substances have been extolled by some and repudiated by others, with the qualities of which medical men are expected to be familiar. Several of these are of un- questionable value in the treatment of diseases; many of them possess doubtful qualities, which have been ascribed to them by tradition or by long usage, whilst a vast number are positively worthless, if not injuri- ous. Bichat says, " There have been no general systems in the materia medica; but this science has been alternately influenced by the prevail- ing theories in physic. From hence proceeds that indefiniteness and un- certainty which mark it even in the present day. It is an incoherent mass of incoherent opinions, and, probably, of all physiological sciences, that in which the inconsistencies of the human mind are most glaring. What do I say ? It is not a science for a methodical and philosophical mind; it ia an incongruous combination of erroneous ideas, observations often puerile, means, at the least fallacious, and formulae as fantastically conceived as they are preposterously combined. It is said, that the practice of com- bined physic has something repelling in it. I will say more : in those principles which connect it with the materia medica, it is absolutely re- volting to a rational mind."* Magendie observes that one chemist is in accord with another as to his fundamental facts, and that the pheno- mena observed in his laboratory are the same in Paris as in New York, in London as in Calcutta. But, he adds, it would be a painful task to pass in review the different modes of medical treatment employed in different localities for the same disease. Even in Paris, should an indi- vidual be attacked by typhoid fever, the treatment would vary, aecord- ing as he was sent to this or that hospital.f Most of our scientific anatomists and physiologists, like Bichat and Magendie, have continued to distrust the influence of medicines in disease, and have taken too little interest in therapeutics. The consequence has been, that the generality of medical practitioners are educated in a blind faith as to the proper- ties and uses of drugs, a faith which has, in most cases, descended to us from a barbarous age, has become traditional, and possesses no relation to the present state of medical science. All those who have acquainted themselves, in recent times, with what is known of the structure and chemical composition of the tissues, the laws of nutrition, and the pathological changes which occur in organs during disease, must feel astonished at the unfounded assumptions, want of evidence, and even unreasonableness which characterise writings on the action of medicines. They are constantly asking, on what grounds the assertions as to the properties of this drug or that treatment are based, and too frequently can obtain no response whatever. We observe also that what now occurs in our hospitals is so often at variance with such assertions, as to create a wholesome scepticism as to the correctness of what is taught of the materia medica. As an example of the writings and teachings on this branch of our subject, let us examine the third and last edition of a work by Dr. Head- * General Anatomy, Translated by Coffyn, p. xiv. f Phenomenes physiques de la vie. Tome 2me, pp. 4 et 5. MATERIA MEDICA. 333 land, which gives what is admitted to be one of the best and most recent systematic accounts of the actions of medicines in our language.*- We may at least regard it as an intelligent and careful resume of the present state of our knowledge. At p. 161, he says: " Another remedy has been used in all the dis- eases in which quina is admissible, proving in some cases superior and in other instances second only to it in its beneficial action. This is mercury; used in remittent and yellow fevers; of the first importance in dysentery; employed by Dr. Baillie in ague, and pronounced by him to be in some cases superior even to quina. In small doses it is frequently of use in cases of debility and scrofula. And mercury is a cholagogue; i. e., an agent which is known to have the effect of promoting the secretory function of the liver." " Under such a course, judiciously enforced, we may see the dilated pupil contract to its normal size, and the pale ener- vated countenance become rosy and lively, and feel the weak compressible pulse become hard and firm. Perhaps mercury in such a case may be indirectly tonic, by restoring to the blood the natural tonic principle of the bile." Again, at p. 213—" Mercury, which restores the secretion of the liver, may be for this reason useful in arthritic diseases." Here, you will observe, that arguing on the principle that whatever restores to the blood such of its constituents as are deficient is tonic, mercury is recom- mended in cases of debility, scrofula, and gout, because it is a cholagogue. But no facts are given to show that mercury is a cholagogue, and if that assumption be incorrect, its alleged value in those diseases falls to the ground as a speculation, while no cases are given to demonstrate it as a matter of observation. At p. 383, it is said, that mercury has been found in the bile of dogs by Burcheim. But any facts to show that the drug increases the flow of bile, I have vainly sought for. At p. 373, Headland says: "It is by the production of nausea that antimony becomes so valuable an agent in the control of high fevers and acute inflammations. The force of the heart being diminished, the fever is allayed; and the active congestion of the vascular system, whether local or general, which was produced by the inflammation and maintained by the violent action of the heart, is effectually subdued. At the same time absorption is favored by the removal of the pressure from the capillary circulation." Here, you observe, it is said that inflammation is cured by nauseants; that subduing the force of the heart subdues fevers, and so on. I trust you have satisfied yourselves in the clinical wards that all depressants and nauseants are opposed to the correct treatment of inflammations and fevers, and that recoveries take place just in pro- portion as we can support the system, and sustain rather than subdue the heart's action. At p. 385, we are told that in treating inflammation, " the imme- diate effect of bloodletting is mechanical; that of antimony, nervous; that of mercury, haematic. Bloodletting weakens the force of the heart, by diminishing the pressure on the blood-vessels; antimony diminishes the pressure on the vessels, by weakening the force of the heart; and mercury does both of these things, by impoverishing the blood." But it is nowhere shown that any of these drugs either act in the way stated, * London, 1859. 334 GENERAL THERAPEUTICS. or cure inflammation at all. So far as modern experience is concerned I hold it on the other hand to be demonstrated, that weakening the pulse, or impoverishing the blood to cure inflammation, is a most fatal practice. I hope you have satisfied yourselves from the results of treat- ment carried on in these wards, that inflammation may be successfully combated without the use of bloodletting, antimony, or mercury. At p. 390, we are told that mercurials " no doubt stimulate the for- mation of the pancreatic secretion, which is similar in nature to the saliva." Now, as to their causing salivation we can have no doubt because we see it; but as to its causing a flow of pancreatic juice, is it sufficient to say there can be no doubt it does, because that fluid resem- bles saliva ? At p. 425, it is said: " In delirium tremens, and in all cases of delirium unattended with high fever, opium may be said to be our sole reliance." Our sole reliance ! Why, gentlemen, during this summer ses- sion of three months (1864), you have seen no less than twenty cases of delirium tremens enter my wards—some of them very severe, and yet they have all got perfectly well without the use of opium in any way. Nay more, I will venture to say that this favorable result is in great part attri- butable to no opium having been administered. (See Delirium Tremens.) At p. 284 we are told of hemlock, that its " paralyzing action on the nerves of motion is directly the reverse of the stimulating action of strychnia; it is thus of use in cases of convulsion and spasm." Now the poisonous effects of hemlock are very peculiar, paralyzing motion from the feet upwards, as was shown in the case of Socrates, and in another well observed case I have myself recorded subsequently in this work, whereas strychnia produces no such progressive effect in any direc- tion. Neither is there one single fact in the annals of medicine which proves that hemlock is of the slightest use in such convulsions and spasms as strychnine produces. I should weary you by further quotations from a book, which, excellent as it is in many respects, is replete with similar statements. Look at any other work on the same subject, and you will find the like kind of asser- tions equally at variance with the present state of our knowledge.* But if objections, such as we have ventured to offer, can be made to carefully prepared works on therapeutics, by gentlemen who have made that sub- ject a careful study, what confidence can be placed in the assertion of practitioners generally, or of hopeful young men entering into the pro- fession. Only read the accounts of distinguished medical men, teachers, and hospital practitioners, men of large experience, as to the effects of bloodletting and other remedies, and then compare them with what you * For example—nothing can be more opposed to the present state of our know- ledge and to the numerous facts contained in this work, than the following sentences which meet us in the first few pages of a work published in 1860, by another distin- guished author on Therapeutics, Dr. Stille:—" It is not pretended that any human resources can secure the arrest of tubercle" (p. 41). "Depletion everywhere modi- fies, at least, the forming stage of inflammation; mercury everywhere acts upon its products " (p. 48). " Depletion is held to be the capital remedy for pneumonia, and experience has for centuries appeared to agree with reason in sanctioning this prac- tice" (p. 49). CURATIVE ACTION OP REMEDIES. 335 have S3en with your own eyes of the successful treatment of inflamma- tions m the clinical wards. Andral tells us that " the experience of ages has taught us to be more prodigal in the taking of blood in pneumonia, than in any other disease ; that there is no period of the disease, no con- dition of the pulse, no apparent debility of system, no age, which forbids its practice." Alison no less emphatically says : " No proposition in medical science is more certain, and certainly none more practically im- portant than that which regards the power of large and repeated blood- letting to arrest the progress of inflammation in its early stage." " In pneumonia, the utmost confidence may be placed in general bleeding, which should always be large and almost always repeated." Now, the proposition which my experience has demonstrated in the clinical wards of the Royal Infirmary, is the very converse to this, and that is, that the rate of mortality in inflammations, and especially in pneumonia is large, just in proportion to the amount of bloodletting and of other antiphlogistic remedies employed. So powerful and so persistent, how- ever, have been the doctrines of the past, that notwithstanding the facts, which I made public in 1857 as to my results in the treatment of pneumonia, and notwithstanding the fact that an antiphlogistic practice in this country is almost universally abandoned, every systematic and compiled work on medicine up to this date (1864) still recommends for that disease bloodletting, to be followed by the administration of anti- mony and calomel. Looking therefore at the discrepancy which exists between systematic teachings and writings on the one hand, and the actual practice in our hospital wards and in private on the other, as to the employment of the materia medica in disease—regarding also the differences of opinion which exist among practitioners of the highest respectability and expe- rience, it will be admitted to be a difficult task to determine what posi- tive knowledge we possess of the value of drugs. Still, I think the time has arrived for attempting it, and, in doing so, I have only to assure you that my views on this subject are the result of long and anxious consideration. I shall describe what is known first of their curative, and, secondly, of their physiological action. First, then, are there any drugs or medical preparations whose effects are unquestionably beneficial in particular diseases ? I think there are, as witnessed by the influence of—1, Quinine in ague ; 2, Pitch ointment in psoriasis ; 3, Male shield-fern in tape-worm ; and 4, Sulphur ointment in scabies. I think no one who has used these remedies in the diseases named can doubt their curative power as a matter of fact, however they may differ as to the mode of their action. Of a similar unquestionable char- acter are the following, although, for the reasons previously stated, the two first should be placed among the dietetica, and the third among the hygienica. They are—5, Cod-liver oil in scrofulous and tubercular dis- eases ; 6, Lemon juice in scurvy; and 7, Constant moisture in eczema- tous and impetiginous diseases of the skin. These seven remedies I put into the first, and the following in the second class—8, Colchicum in acute gout; 9, Iodide of potassium in certain forms of periostitis; 10, Iron in chlorosis and amenorrhcea; 336 GENERAL THERAPEUTICS. 11, Arsenic in scaly skin diseases; 12, Copaiba and cubebs in gonorrhoea* 13, Nitro-muriatic acid in oxaluria; 14, Supertartrate of potass in Bright's disease, with diminished urine and dropsy; and 15, Oils and fats in para- sitic diseases of the skin. These remedies, though not so valuable, must, I think, be admitted to be also curative in certain cases, by the majority of practitioners. As to bloodletting in inflammation, mercury in syphilis, and iodine in scrofula, I consider their value, though highly lauded by some, to be more than questionable. The fifteen remedies named, therefore, I consider to constitute all the positive agents we possess capable of curing diseases or morbid states when they are once fairly established. Many other drugs relieve symp- toms—are palliative and most useful during our treatment of disorders —but, I repeat, as curative, I shall only be too happy to hear of any I have omitted. But there are other agents which, although they do not possess direct curative powers, remove pain and particular symptoms, and enable us, with the assistance of the dietetica and hygienica, indirectly to bring about recovery. Among these may be cited—Bismuth and alkalies in heartburn; Purgatives in constipation; Opium, chalk, and astringents in diarrhoea; Ethers in asthmatic dyspnoea; Naphtha and hydrocyanic acid in dyspeptic vomiting; Narcotics in local pain ; Chloroform in sus- pending sensation ; Belladonna and the Calabar Bean in certain diseases of the eye; Santonine in ascarides; Counter-irritants, in various kinds of local pain ; and small Bloodlettings in aneurisms, pulmonary conges- tions, and hypertrophied heart. To these may be added, certain essen- tial Oils, and Assafcetida, in flatulence—Sudorifics and Diuretics to meet peculiar indications—Nitrate of Silver locally in ulcers, etc. etc. Such, then, are the chief articles of the materia medica I am acquainted with that can be shown to be of direct therapeutical value—discovered during the last two or three thousand years by the medical practitioners of civilized nations. To some this result may appear to be insignificant, but by those who are capable of appreciating the difficulty of establish- ing the therapeutical value of medicines, it will be admitted that the use of these remedies has proved of incalculable benefit to mankind. In the second place, let us consider what is known of the action of the materia medica on the functions of the various tissues and organs of the body in a state of health. Action of Medicines on the Ultimate Elements of the Tissues. Molecular elements.—We have no drugs, properly so called, capable of influencing the activity of the molecular element of the body, unless we include cod-liver oil, which increases the molecular constituents of the chyle, but which, for reasons previously stated, we class among the dietetica. In one sense it is true it may with reason be maintained0that all medicines operate on this element of structure. This, as a theory of the ultimate action of drugs, will be referred to subsequently. The cell elements.—Beyond what we are acquainted with, concern- ing the albuminous, fatty, and mineral elements, which enter into the PHYSIOLOGICAL ACTION OF REMEDIES. 337 structure of cells, we are ignorant of any medicinal substances known to affect them especially. The tubular elements.—The nerve tubes are differently affected by numerous substances, which we shall refer to under the head of nervous system—and the minute blood tubes are especially dilated by a new sub- stance—the nitrate of amyle—which Dr. Richardson has shown experi- mentally to have this property. Fibrous elements.—We have no knowledge of any especial agents which act upon the molecular, areolar, or elastic fibrous tissues. The muscular and probably other contractile fibres, generally are supposed capable of being influenced by a class of remedies called tonics. But when we investigate closely into what this tonic property consists, we find it to be anything which removes debility. Hence it has been ascribed to stimulants, nutrients, vegetable bitters, and mineral salts, and great discussion has arisen whether these operate through the nervous system or through the circulation—whether they stimulate appetite or impart directly restorative qualities to the blood—the truth is we know little or nothing on these topics of a positive character, and may rest assured that nutritive food and proper exercise are the real agents through which strength is imparted to the muscular system. Cartilaginous and osseous tissues.—These textures have the peculiar property of separating from the blood and fixing large quantities of mineral matter, which, of course, must enter the body in the food and drink. Of any method of increasing or modifying this peculiar pro- perty we are profoundly ignorant. Therapeutists generally in their writings, although certainly not de- ficient in all sorts of theories as to the actions of medicines, have cultivated very little a knowledge of the ultimate composition or structure of thos3 tissues or organs on which their remedies operate. This is one of th3 reasons why their views give such little satisfaction to the modern scientifi3 inquirer. Action of Medicines on the Nervous System. Many articles of the materia medica produce decided effects upon dif- ferent parts of the nervous system, stimulating or perverting some, and destroying or suspending others. From the circumstance also that thesa effects have, to a great extent, been largely studied by physiologists, as the result of experimental investigation, our knowledge with regard to them is much more precise than it is with respect to many other drugs. They have been classified according to their stimulating, narcotic, or seda- tive properties, understanding by stimulant, what excites nervous func- tions, by narcotic, what first increases, then depresses it, and by sedative, what depresses it. I shall refer to them, however, according as their action principally affects the brain, spinal cord, or nerves. Cerebral functions.—These are influenced by opium and most of the pure narcotics, which first excite and then depress or destroy the mental faculties. According to Flourens, opium acts on the cerebral lobes, while belladonna operates on the corpora quadrigemina. The first causes contraction, and the last dilatation of the pupils. Tea and coffee are pure excitors of the cerebral functions, and cause sleeplessness. Alco- 22 338 GENERAL THERAPEUTICS. holic drinks, ether, chloroform, and similar stimulants, first excite and then suspend the mental faculties, like opium. The modern practice of depriving persons of consciousness, in order, for a time, to destroy sensation, has been very much misunderstood, in consequence of such remedies having been erroneously and unscientifically denominated an- aesthetics. The fact is, they influence local sensibility, or the sense of touch very slightly if at all. Their action is cerebral, and in large doses spinal. Hence the danger which occasionally attends their action. Spinal functions.—Strychnine acts especially as an excitor of the motor filaments of the spinal cord, causing tonic muscular contractions, as in tetanus from spinal arachnitis, or from the irritation of a wound. Worari produces exactly an opposite effect, causing paralysis and reso- lution of the same parts. Conium paralyses the motor and sensitive spinal nerves, producing paraplegia, commencing at the feet and creeping upwards. (See case of Duncan Gow, p. 460.) Picrotoxine, according to Dr. Mortimer Grlover, causes the animal to stagger backwards, as in the experiments of Magendie on the Crura Cerebelli. Tobacco is a powerful sedative and depresses all the spinal functions. Cerebro-Spinal functions.—Hydrocyanic acid in poisonous doses, acts conjointly on the cerebrum and spinal cord. All the animals I have seen killed by this agent utter a scream, lose their consciousness, and are convulsed. These are the symptoms of epilepsy. Cold is at first an excitor of the spinal functions, and is a strong stimulant to diastaltic activity, but, if long continued, produces drowsiness and stupor. Neuro and Neuro-Spinal functions.—These are especially affected by the action of certain metallic poisons, such as mercury, which occasions irregular muscular action with weakness, and lead, which causes numb- ness and palsy, most common in the hands. On the other hand, can- tharides stimulates the contractions of the neck of the urinary bladder, and secale cornutum those of the pregnant uterus. Stramonium acts as a sedative to the nerves of the bronchi. Aconite operates powerfully in paralysing the action of the heart, through the cardiac nerves of the vagus, while antimony excites vomiting by acting on the gastric and other branches of the same nerve. Belladonna also has a peculiar local influence in causing dilatation of the pupil, while the Calabar bean has the opposite effect, producing its contraction. The secretion of the lachrymal gland is increased by the pungent emanations from onion, garlic, squill, and mustard. Organic Nerve Functions.—It is now some years since I put forth the idea that quinine, salicine, and the allied compounds, have a special influence over the sympathetic or ganglionic system of nerves, controlling and exciting their power, and thus influencing those periodical functions connected with nutrition, secretion, and growth. The experiments of Bernard, Brown-Sequard, and others, have now proved that these are in- timately connected with this part of the nervous system—irritation of these nerves causing cold and pallor, while section or destruction of them induces increased heat and redness. Pereira supposed that stimulants and sedatives especially acted upon this system of nerves, but, unques- tionably, they also act on the brain. It must be further observed that, although the primary action of PHYSIOLOGICAL ACTION OF REMEDIES. 339 these narcotic medicines is such as I have stated, that in large doses their influence is more extended, and their operation is more diffused over the nervous system. Thus, chloroform may not only act on the brain, but on the spinal cord. It is very probable also that most of the medicines which have an unequivocal action on special organs, do so by operating on the nerves distributed to them, through the medium of the blood. Action of Medicines on the Respiratory System. Diffusible stimulants, more especially the ethers, have an unques- tionable effect in checking or relieving dyspnoea,which is probably owing to their action on the heart and circulation generally, rather than on the lungs specially. Whether there is such a medicine as a true expectorant, that is, one capable of increasing the secretion from the bronchial mucous membrane, is, in my opinion, quite uncertain. Even Headland admits, that, on this point, no investigation has been made (p. 325). That antimony, ipecacuanha, squill, and other drugs possess this property, however, has been so generally assumed, that they are constantly em- ployed in all cases of cough, with or without expectoration, and lengthened discussions have occurred as to whether such remedies act on the glands of the mucous membrane, or upon the muscular fibres of the bronchial tube. In the meantime, the uncertainty of their action is admitted, and there are no series of observations extant, so far as I am aware, which prove that they act at all. The lungs have been made the vehicle for the introduction of medicines in a state of vapor from ancient times, and the discovery of the effects of ether in producing insensibility to pain has only served to extend the practice. Action of Medicines on the Circulatory System. Numerous remedies have been employed for the express purpose of diminishing and increasing the rapidity of the circulation and the force of the pulse, as well as the quantity and quality of the blood. This can be done directly by bloodletting and starvation on the one hand, and by stimulants and generous diet on the other. Certain drugs are supposed to have an especial action on the nerves of the heart, more especially aconite and digitalis. Veratrum viride has recently been extolled as being capable of diminishing the force of the pulse, which I have myself seen it do, by acting as a depressing acrid poison to the system generally. Other remedies are imagined to act on the capillary circulation when ruptured, and to be capable of arresting haemorrhage from them ; among these are acetate of lead and gallic acid. But how these drugs, intro- duced into the stomach, should produce this effect, has never been shown, and there are no series of observations which establish their alleged influence, although, as in the case of expectorants, the assump- tion is generally acted upon. The Blood.—All soluble remedies introduced into the economy are absorbed into the blood. They may act on the nerves or distinct parts through it, but there are some which act upon the blood itself, adding to or detracting from its constituents. The former are restoratives, the 340 GENERAL THERAPEUTICS. latter are named by Headland catalytics. Among the former we must never forget that aliment holds the first place, and that it is by restoring what is deficient, or detracting from what is in excess in the diet, that many medicines operate; as when cod-liver oil is given in scrofula, or lemon-juice in scurvy. To exactly the same principle I would refer the operations of alkalies and acids, which, by forming new combinations in the blood, serve to restore or correct morbid conditions of that fluid. The same may be said of salines and of chalybeates. It should be ob- served, however, that several of these remedies can only be considered restorative, on being added to the blood in proportion somewhat similar to what exists in health; but that, if introduced in excess, so far from being beneficial, they are absolutely destructive. In cholera, for instance, it was shown by Dr. Stevens that the saline constituents of the blood were greatly diminished. They were, in consequence, dissolved in water, and large quantities of the solution injected into the veins. The effect appeared, at first, to be miraculous: persons on the point of death recovering in a wonderful manner. But as excess of water and saline matter dissolves the blood corpuscles, all these persons, after a few hours, again sank and died. In their attempts to introduce chemical remedies and form chemical combinations, therapeutists have too often overlooked the fact, that in order to act as restoratives, drugs must facilitate the addition of structural elements to the economy. Hitherto, however, very few of the writers on this subject have been histologists.' Mercury has been supposed capable of dissolving the fibrin of the blood, and thereby of favoring absorption of coagulable lymph. For the same reason it has been considered antiphlogistic. These views are connected with the exploded theory of inflammation commencing in in- creased fibrinosis, and have been shown, by modern experience, to be altogether erroneous. The assumption that many diseases originate in the blood, has led to the employment of a variety of medicines called specifics, which, in the opinion of some neutralize in that fluid the particular agency producing the disease. There is no theory which the modern inquirer should dis- trust so much as this, or with regard to which he should demand more rigorous proof. The tendency of modern physiology and of modern ex- perience is to show the fallacy of the reasoning on which this doctrine has been supported. For example, iodine has been supposed to be spe- cific in scrofula, mercury in syphilis, antimony in inflammations, colchi- cum in gout, etc. etc. We now know that scrofula is to be removed best, not by giving a poison which acts as a specific or alterative, but by improving nutrition. We shall subsequently see that syphilis has been cured, in recent times, just in proportion as we have ceased to give mer- cury. Antimony, in contra-stimulant doses, is a fatal practice in acute inflammations. And if colchicum be useful in gout, it is not by acting as a catalytic or blood-destroyer. If by specific, again, be meant remedies operating in an unknown manner, it is only reasonable to believe that, as knowledge advances, and we obtain glimpses of how medicines operate physiologically, the idea of specifics should be banished from therapeutics. The Blood Gla?ids.—\Ye are unacquainted with any medicine which has an especial operation upon the lymphatic system of glands, more espe- PHYSIOLOGICAL ACTION OF REMEDIES. 341 cially as sanguiferous organs. Generous food, and cod-liver oil, increase the amount of chyle. Iodine is said to diminish the size of the thyroid, when hypertrophied in bronchocele; and, according to Piorry, quinine, in large doses, almost immediately decreases the enlarged spleen in in- termittent fever. Further observations, however, are required to estab- lish either supposition. Action of Medicines on the Digestive System. In consequence of medicines being directly introduced into the digestive tube, we have to distinguish two kinds of operations, viz., such as act locally, and such as act secondarily on other parts of the body, through the medium of the blood. Salivary Glands.—These glands are always called into action during mastication, and may be excited by the aid of sialagogues. Here the in- fluence of mercury is unquestionable, profuse salivation being the leading symptom of its peculiar action on the economy. Chewing tobacco, pyre- thrum, betel, and some other irritating substances in the mouth, produce the same effect locally. The Pharynx and Oesophagus are said to be rendered dry, and to be spasmodically contracted by belladonna. Stomach.—The reflex action of vomiting may be excited in various ways—1st, By giddiness and vertigo arising from the motion of a ship at sea, or of a swing. 2d, By a variety of cerebral diseases. 3d, By the mental feeling of disgust or of irritation. 4th, By certain peculiar irritations, as that of a gall-stone. 5th, From pregnancy. 6th, By the introduction of certain medicines called emetics, some of which act in this way whether taken into the stomach or whether injected into the blood, such as antimony. In all these cases, therefore, the action is owing to nervous irritation, and when produced by drugs, these apparently act through the blood on the vagi nerves. Other emetics, such as sulphate of zinc or oxide of arsenic, act through their topical irritant properties. The secretion of gastric juice may be increased by stimulants, and if in excess be neutralised by antacids, such as bismuth, magnesia, and alkalies. It is thought also that its digestible properties, which partly depend upon its acidity, may be increased by small doses of hydrochloric acid. (See General Pathology and Treatment of Dyspepsia.) Liver.—Although mercury, taraxacum, and some other remedies, are generally supposed to have the property of increasing the secretion of this organ, it still remains to be proved whether this is the case or not. Indeed, I am acquainted with no series of observations which demon- strate that an increased flow of bile has been unequivocally produced by any known remedy. Pancreas.—We know of no remedy which influences the functions of this organ. Intestinal Glands.—All local irritations excite these glands to an increased action, and numerous purgatives, especially the more drastic ones, are supposed also to induce increased excretion from them. Others, such as elaterium, are imagined even to cause separation of serum largely from the blood-vessels. We now know that immediately below the intestinal mucous membrane, there is a rich layer of organic nerves, 342 GENERAL THERAPEUTICS. which not only supply the glands, but the blood-vessels and muscular layers also, and so regulate secretion, excretion, and peristaltic motion. There is no difficulty, therefore, in supposing theoretically that the special action of many purgatives is through the blood on this portion of the nervous system, although we have still no proof of it derived from experiment. Intestinal Tube.—Numerous remedies excite the peristaltic action of the digestive canal. They are called purgatives, and are derived from the animal, vegetable, and mineral kingdoms. There can be no doubt that saliva, bile, the pancreatic juice, and other fluids secreted in the alimentary canal, are natural stimulants to its proper action; and when any one of them is deficient, constipation is the common result. Excess of bile, purges, mechanical irritants, also excite intestinal action, as the undigested husks of vegetables, small seeds, powdered tin, and so on. Purgative drugs may act either locally or constitutionally, sometimes in both ways. The more acrid, such as gamboge, may act principally in the one way; and the more bland, such as neutral salts, more par- ticularly in the other. It has been shown, however, that the true pur- gatives, like the emetics, when introduced into the circulation directly through a vein, produce their peculiar local action. It has been sup- posed that some of them, such as rhubarb, act more especially upon the upper part of the canal; and others, such as aloes, operate more par- ticularly on the lower portion of it. Seeing that we have unquestionably drugs that operate on the stomach, and others on the bowels, it may easily be conceived that among the numerous purgatives which exist, several of them may act on distinct parts of so lengthy a tube. But this has by no means been clearly proved. Another class of remedies, known as astringents, have the opposite effect to purgatives—some diminishing mechanical irritation, and others having a direct constringing effect on the muscles and blood-vessels. Among the former are demulcents, antacids, and opiates. Among the latter, catechu, kino, gallic acid, and others from the vegetable; and sulphuric acid, alum, nitrate of silver, iron, and others from the mineral kingdom. Introduced into the alimentary canal, whether by the stomach or rectum, their action is local. That they ever operate on distant parts through the blood is doubtful. One of the most valuable astringents for the stomach is ice, and for the lower part of the bowel cold water, used as an injection. Medicines used to expel worms from the alimentary canal are called anthelmintics, and the influence of some of these is unquestionable. Some act mechanically, as powdered tin, and others by their purgative qualities; while a third class appear to exercise a poisonous influence over the parasite. Of these last, the most powerful is the essential oil of the male shield-fern, which kills the taenia solium. Action of Medicines on the Genito- Urinary System. We have no proof of any direct aphrodisiac properties existing in drugs. The same may be said with regard to emmenagogues, or medicines supposed capable of increasing the catamenial discharge. In cases of PHYSIOLOGICAL ACTION OF REMEDIES. 343 amenorrhcea, chalybeates and other tonic remedies are usually prescribed, but too frequently with indifferent success. Ergot of rye stimulates the contractions of the uterus during labor. The secretion of the mammary gland is said to be affected by drugs administered to the mother, especially by acrid vegetable purgatives, and by bitters, such as worm- wood, and that in this way they operate on the infant. The existence of any true lactagogue has yet to be proved. Medicines which increase the flow of urine are called Diuretics. Of these, the most powerful are certain alcoholic preparations, such as nitric ether and gin, a few vegetable substances, such as digitalis and squill, and some salts, such as the supertartrate and the acetate of potash. The effect of these remedies is unequivocal, and their curative influence, in certain cases of Bright's disease, has frequently been demonstrated by me in the clinical wards (see Bright's disease, case of Herdman). We know of no drug capable of checking the urinary secretion. It has been said that colchicum has a special action in eliminating urea from the kidney (Maclagan), although this has been disputed (Garrod). Can- tharides appears to influence more especially the urinary bladder, causing contractions in its neck and strangury. Camphor is said especially to allay vesical irritation, although I have never seen it produce that effect. Certain balsams, especially that of copaiba, and the essential oil of cubebs, have an unquestionable influence in diminishing purulent discharges from the urethra, an effect probably owing to their local action, as they pass over the mucous membrane, dissolved in the urine. Action of Medicines on the Integumentary System. Remedies that increase the watery secretion from the sudoriferous glands are called Diaphoretics. This effect is also occasioned by exer- cise, warmth, and especially heated air—indeed anything that increases the circulation of blood in the skin. It is also a symptom of exhaustion, however occasioned, and is therefore present in all diseases which rapidly depress the system, as acute inflammations, fevers, phthisis, etc. The stronger a man the less easily he sweats on exertion. All nauseat- ing and depressing remedies are diaphoretic, such as antimony, ipecacu- anha, as well as narcotics, which after excitement produce a sedative in- fluence. We are ignorant of any medicines which increase the sebaceous secretion from the skin. The skin may be made the vehicle for introducing medicines into the blood—1st, By friction, as in rubbing with mercurial ointment, when salivation is occasioned; 2d, by inoculation, as in the artificial produc- tion of cow or small pox; 3d, by abrasion, as when powdered opium or strychnine is sprinkled over a blistered surface; and 4th, by injection, as when morphia in solution is injected into the subcutaneous cellular tissue with a syringe and a finely-pointed steel canula; 5th, by vapor. Artificial irritations of the skin, to produce internal or distant effects, are caused by what are denominated counter-irritants, including stimu- lants, frictions, hot applications to parts, sinapisms, blisters, moxas, cauteries, etc. etc. These all operate through the nerves by reflex action : some, like warm fomentations, soothe irritation; others, as blisters, create 344 GENERAL THERAPEUTICS. it locally, but remove it from where it was primarily seated. How this is accomplished constitutes one of the most vexed questions in thera- peutics. Where there is breach of surface in the skin, eruptions or ulcers, various applications are made to it, constituting special treatments in medical and surgical practice. In the short general account now given of the physiological action of medicines, my object has been not to make an enumeration of drugs, but to point out what influences can and cannot be exerted by them over the functions of the animal economy, according to the present state of our knowledge. Systematic writers on therapeutics are fond of grouping remedies together according to their presumed qualities, either as modi- fying function in health, or restoring health during disease, constituting what have been called the physiological and therapeutical arrangements of drugs. Great confusion has resulted from both systems, because, as we have seen from the previous inquiry, our positive knowledge of either is very limited. It follows that they deal largely in assumption and loose analogies. One drug is often made to play many parts, and often possesses the most contradictory qualities. What we require is exact knowledge with regard to them, and this can only be arrived at by.de- termining in the first place their simplest uses. Even here, as we have seen, there is yet much to learn. Let us next inquire the mode in which they act on the animal economy. General TJieory of the Action of Remedies. Drugs may act topically on the parts to which they are applied; on distant parts by reflex action through the nerves, and by selective affinity between the tissues and the blood. Great discussion has > taken place as to whether certain medicines operate directly on the nerves or through the blood. The fact that the entire circulation is accomplished in about half a minute (Hering, Blake) is quite sufficient to account for the rapidity of the most active drugs, even of poisonous doses of hydrocyanic acid; whilst it has been proved that medicines which act strongly on the nerves, when they are , taken into the stomach, such as worari, have no effect when applied to the nerves themselves (Kolliker). Indeed, it has been shewn that some remedies when applied directly act on muscles, others on nerves, and a third class on both (Kvihne). In the living body, however, activity of the circulation is necessary for the operation of remedies, and we observe that whenever it is too languid from exhaustion they fail to operate. It is fur- ther to be observed that by whatever channel a drug with characteristic properties is introduced into the system—whether by the stomach or the rectum, by the skin or the lungs—the effect is exactly the same as if it was introduced into the blood itself. It follows that the active pro- perties of drugs are first absorbed into the blood (Magendie), and then act upon different tissues, exerting or diminishing their functions, in consequence of a property of attraction and selection exerted by the molecules of the tissues themselves. In this respect druo-s act in the GENERAL THEORY OF THE ACTION OF REMEDIES 345 same way that articles of diet do. In virtue of vital powers, whereby one tissue attracts and selects from the blood fat, another albumen, and a third mineral matter—or one gland attracts the materials out of which it forms bile, while another attracts the substance which it forms into urea— so does this tissue attract and select from the blood the peculiar property of one drug, and another tissue that of a different one. This is the only explanation that can be offered of why ipecacuanha acts as an emetic and aloes as a purgative; why opium acts on the brain, causing sleep; and strychnine on the spinal cord, causing spasm; why mercury stimulates the salivary, and supertartrate of potash the renal glands. This theory accounts also for the degrees and varieties of disordered function pro- duced by different drugs of the same class. The existence of such properties in drugs, or, more strictly speaking, in the living tissues to which through the blood parts of these drugs are carried in solution, are ultimate facts in the science of therapeutics. At the same time it may be understood that in a few cases impressions made upon the extremities of sensitive nerves act according to the laws of reflex action, as when counter-irritants relieve internal pain, or when sternutatories induce sneezing. The study of these various facts must ever furnish the proof that all exact explanation and knowledge of the action of drugs must spring from physiological investigation. It has been very generally supposed that if one drug exalts action and another depresses it, the effects produced by the first may be counteracted by the second. But this does not always follow. For example, strychnine evidently excites the motor nerves to action, and worari as certainly paralyses them. As medicines, however, the one has no counteracting effect to the influence of the other. Poison an animal first with strychnine and then with worari; so far from health resulting, the death of the animal is rendered doubly certain. Experiment and experience are here both opposed to a theory which lies at the basis of much of our practice. I have given strychnine in numerous cases, and in all forms of paraplegia, and have yet to find a single instance in which any benefit resulted from its administration. Again, in delirium tremens there is great wakefulness: it might be supposed that giving opium, which causes somnolence, would cure the former symptom; yet I have i frequently satisfied myself that so far from doing so it exasperates and prolongs the malady. Exactly on the same principle strong coffee and tea have been given to cause wakefulness in cases of poisoning by opium, but in no one instance have they been shown ever to produce the desired effect. The reason of all this appears to be very obvious. Each drug has an affinity for certain parts of the nervous texture. The ultimate tubes or especial centres acted upon by strychnine, are not those which are influenced by worari. Neither is the nervous matter affected by alcohol or opium that which is impressed by coffee or tea. Another very general idea prevails, viz., that a medicine decidedly curative, such as quinine in intermittent fever, is also prophylactic, and will keep off the disease. It is difficult to understand how this can be true in theory; and in practice, though largely acted on, we are as yet destitute of any demonstrative facts in its support. It is now recognised that medicines derived from the organic world 346 GENERAL THERAPEUTICS. owe their peculiar action to certain principles which they contain, and which the chemist can abstract from them. Thus from Peruvian bark is extracted quinine; from opium, morphia ; from nux vomica, strychnine; from belladonna, atropine, and so on; and experiment has demonstrated that the peculiar properties of the drugs are not only possessed by, but intensified and concentrated in these preparations. The art of phar- macy therefore has greatly advanced of late years, and placed in the hands of physicians medicines capable of acting with far greater power and certainty than formerly. The notion that disease is a something which, having got in, requires to be driven out of the system—is an enemy that we must attack, lay siege to, and conquer—is one that largely prevails in the works of thera- peutists.—" The intestinal canal is, in the great majority of cases, the battlefield where the issue of the most important disorders is decided."— (Hufeland.) " We must introduce the only medicine of which we are thoroughly convinced that it possesses the power of efficiently striving with the enemy who, by subtle means, has now effected an entrance within our stronghold."—(Headland.) " The whole of life is a perpetual struggle with an enemy to whom we must at last succumb."—(Stille.) These expressions, however metaphorical, indicate the kind of operation sought to be carried out in treating disease. The active practitioner, like the victorious general, is more intent on driving out the enemy, than in securing the safety of the fortress, which during the operations of both is too often greatly damaged, and not unfrequently levelled to the ground. But the truth is, in many cases what we call disease, instead of being an enemy is our best friend. It should be regarded as the natural and necessary result of those injuries to which the animal econ- omy is necessarily exposed. It is the effort made by nature to elimi- nate from, or reconcile the frame with, those noxious causes which have influenced it. If it cannot do this, the vital force is exhausted. Our great object, therefore, should be, not to suppress, but to favor the natural operations of diseases, and conduct them to a favorable termination. If a sword is thrust into the flesh, should we suppress the pain, heat, redness, and swelling which result ? No; for they are the evidence of those healthful changes, which, properly managed, will heal the wound. If the lung be inflamed, should we seek to check the dyspnoea, arrest the fever, and weaken the pulse ? Again I say no. They are the proofs that the constitution is actively at work in re- pairing the injury, and preparing the way for recovery. Neither can it be correctly supposed that life is a constant struggle with death. On the contrary, death is the natural termination of life; and so far from being an evil, can only be so considered, when it is induced by violent or unnatural means. Another circumstance should not be overlooked, and that is the correctness of the observation made at the commencement of this century by Bichat, viz.—that the science of therapeutics has not been, as is alleged, founded on rigid observation and experience, but on " the pre- vailing theories in physic." Thus it is that when the theory of inflam- mation regarded fulness of the blood-vessels as the essence of that disease, the practice which resulted was of course blood-letting. So TRUE FOUNDATIONS FOR MEDICAL PRACTICE. 347 long as a full and rapid pulse was imagined an injurious symptom, its reduction by antiphlogistics was thought to be a matter of necessity. It is strange that the persons who delighted to call themselves practical men, never perceived that their practice was a most fatal one. Now the theory is changed, and the practice is changed with it; and the proof that the last theory is superior to the former one, is that the mortality from cases of acute inflammations is greatly diminished. It follows that the true method of advancing our knowledge of how to treat disease for the future, is not blindly to go on repeating the routine practice of our forefathers, but to improve our theory of morbid processes, and then re-investigate, with all the aids of modern science, the effects of remedies. This leads me to the last general proposition we have to discuss. PHYSIOLOGY AND PATHOLOGY THE TRUE FOUNDA- TIONS FOR MEDICAL PRACTICE. When we investigate closely into what is actually known of our the- rapeutical means, divided into alimenta, hygienica, and materia medica, it will be seen that we have few exact details founded on scientific re- search. What we require is, that such details must be first arrived at, and then applied in accordance with pathological laws. These point out that all treatment must be general and special—general as regards the nature of the disease, special as regards its seat. The great problem in conducting any given case is to carry out both indications, so that one does not interfere with the other. If, for example, the object be to favor the removal of inflammation or tubercle from the lung, the means requisite for that end must not be put aside or counteracted by a desire of alleviating pain, breathlessness, or expectoration. Indeed, one point of great importance, and which clinical observation has in recent times made manifest, is, that general and local symptoms fre- quently bear no relation whatever to the fatality of the lesion. Thus, an extensive acute inflammation of the lungs, a febricula, or an impacted gall-stone, may cause the most violent symptoms and perturbation of the economy, and yet spontaneously terminate in recovery in a few days; while a phthisis, a pleurisy with effusion, or even a pneumothorax, which may permanently destroy the action of a lung, may come on imperceptibly, and cause only trifling functional symptoms. To the pathologist, therefore, such symptoms are no longer the same guides to treatment as they used to be. They do not so much excite his regard as the structural or chemical lesions which produce them, for he knows that the former will disappear if the latter are removed. It need not, therefore, excite surprise that as our knowledge of pathology has advanced, and our means of diagnosis have improved, we direct our attention more to morbid alterations and less to the temporary effects. In this way it has gradually become manifest that so far from doing good by attempts to relieve symptoms, we too often do harm to the disease. If, for instance, impaired digestion cause headache and sleeplessness, the relief of these symptoms by morphia is anything but beneficial, inasmuch as it depresses the nervous system and diminishes 348 GENERAL THERAPEUTICS. ■the appetite, and so increases the real disease. For the same reason, of what advantage can sedatives and cough mixtures be in phthisis ? The true indication for treatment is to strengthen the appetite, increase the nutrition, and invigorate the frame. Medicines which only tempo- rarily lull irritation, create nausea, destroy appetite, and favor diapho- resis, however they may relieve symptoms, can never arrest the disease. An observation of the mode in which the various sciences are evolved will show that their progress has been more or less influenced by that of collateral branches of knowledge, and especially by the invention of ingenious instruments, the use of which has led to the discovery of new facts. Let us consider for a moment how the rude art of navigation possessed by the ancients was improved by the invention of the mariner's compass; how astronomy is dependent on mathematics, and on the tele- scope ; how natural philosophy, by inventing steam-engines and electrical instruments, has added to all the comforts of life, and so on. It would be as absurd to reproach the ancients with ignorance of navigation, or of railways, because they were unacquainted with the mariner's compass and with the power of steam, as it is to charge medical men with igno- rance of therapeutics, until physiology and pathology are so advanced, that diagnosis and the action of medicines are better understood. Now I am anxious to impress upon you that this is not to be done by the method hitherto pursued by the profession. Most young men on entering practice endeavor to impress upon their memory, by repeated trials, the methods and formulas of their predecessors. This has been done so often that little more can be expected from such a system. On the other hand, the more we consider the flood of light which has been poured upon our art by the physiological discoveries of Harvey, C. Bell, Magen- die, Marshall Hall, Schleiden, Schwann, and others, the more it must become apparent that the true way of cultivating medicine is by prose- cuting researches in physiology and pathology. This conclusion in no way invalidates the necessity of observing the effects of medicines at the bed-side. It only points out that the reason we have made so little progress in therapeutics of late years, is in consequence of the imperfect condition of the sciences necessary to its evolution. Some, it is true, may argue that many of our triumphs in practical medicine have no such scientific foundation. But of these I would remark, that although the mere remedy may have been acciden- tally applied in the first instance, still the cause, diagnosis, and course of the disease were pretty well known, and that from these the pathology could be correctly inferred. For example, in ague and scurfy, the diagnosis is easy. The causes—malaria in the one case, and imperfect diet in the other; and the pathology—a morbid state of the blood—were known. The progress of these diseases was also recognised to go on from bad to worse so long as the cause continued. Then it was ascer- tained that Peruvian bark and lemon-juice removed these morbid condi- tions. Why the one should be removed by the first remedy, and the other by the second, has still to be discovered. All I contend for is, that therapeutical trials cannot be expected to be useful, unless they be preceded—1st, by an accurate diagnosis of the disease; 2d, by a know- TRUE FOUNDATIONS FOR MEDICAL PRACTICE. 349 ledge of its pathology; and 3d, by an acquaintance with its natural progress. Not long ago a young American physician brought binder my notice a tincture of the veratrum viride, which he maintained possessed the power of diminishing the force of the pulse, and said that on this account it was a most valuable medicine in fevers, inflammations, and other diseases where the pulse was excited. But pathology indicates that so far from lowering the pulse in these disorders, what is required is in truth to support it, for the reasons I have formerly mentioned. Indeed, I cannot conceive any circumstances in which such a remedy, even if it possessed the virtues ascribed to it, can be useful. But it so happens that several years ago Dr. Norwood, of Nashville, in the United States, was good enough to send me a bottle of the tincture, which I tried in several cases of fever in the infirmary. In. every instance the medicine caused violent vomiting, pain in the stomach, weak pulse, and symptoms of collapse, and had to be discontinued; but in no one instance did it shorten the disease or improve the symptoms—quite the contrary. Yet this remedy is once more recommended to us on the ground of subduing, not a disease, but a symptom, although everything we know of pathology and the natural history of fevers and inflammations is entirely opposed to its employment. In the same manner hosts of new drugs, or new preparations of old ones, are constantly extolled and recommended on the most insufficient data, few seeming to think it necessary to make experiments, careful observations, or deductions, but appealing only to a very limited expe- rience. But we have previously seen, even where experience has been universal and unanimous—as in the case of bloodletting in inflam- mations—what mischief and error have arisen from unacquaintance with physiology and pathology. As another example, let us for a moment consider the contradictory opinions that prevail with regard to a medicine which, perhaps, has been more extensively tried than any other: I allude to mercury. I need not cite the extravagant praises which it has received from its partisans. It will suffice to say, that one of the most accomplished professors of materia medica in those times tells us that, physiologically, it is " a cor- rosive, irritant, errhine, cathartic, and astringent; a stimulant, diuretic, diaphoretic, cholagogue, and emmenagogue ; and an excitor of that pecu- liar state of the constitution denominated mercurial action, of which salivation is one of the chief local signs. Therapeutically," he says, " it is antiphlogistic, alterative, sedative or contra-stimulant, deobstruent, antisyphilitic, and anthelmintic."—(Christison.) A drug possessed of such wonderfully extensive and varied powers should certainly by this time have had its virtues universally recognised; yet the fact is, that with the exception of its action as a sialagogue and a cathartic, there is scarcely one other of its supposed virtues that is not disputed. Is mercury a cholagogue ? We have no proof whatever that it increases the secretion of bile ; and the only experimental investigation with which I am acquainted—viz., that of Dr. Scott, who gave calomel to dogs, and then collected the bile through a fistulous opening made into the biliary duct—found it in three days to diminish the quantity of 350 GENERAL THERAPEUTICS. that fluid.* Is it an antisyphilitic ? In recent times it is admitted that syphilis has diminished in intensity just in proportion as the use of mer- cury has declined ; and the gigantic experiments made on entire garrison regiments in France, Germany, and Sweden, prove that the non-mercurial treatment of syphilis is far superior to the mercurial in every respect. Is it antiphlogistic ? All that we know of modern practice negatives the idea. Does it cause absorption of lymph or the coagulated exuda- tion ? The clinical observations of Professor John Taylor, of London in pericarditis, and of Dr. Williams, of Boston, United States, in iritis are opposed to such a supposition. Then as to its mode of administration what differences exist! Some give it in large, others in small doses—some in acute, others in chronic diseases of the same kind. Some argue that it should precede, others follow venesection. Some combine calomel with blue-pill to intensify its action ; others with opium for the same reason. Its applications are so numerous and contradictory, that the question may well be, not for what diseases is it useful, but rather which has not been represented to be benefited by this drug ? In the meantime, it is admitted on all hands, that it arrests the appetite, checks nutrition, excites a peculiar fever and erethism, produces a coppery taste in the mouth, furred tongue, and sali- vation ; and the pathologist may well inquire how a poison operating in such a way can have any curative tendency whatever. Now, why all this uncertainty as to the therapeutic action of drugs ? My answer is—In consequence of our ignorance of an exact diagnosis and of a true pathology. Many persons think that the science of thera- peutics is to be advanced by trying the effects of drugs on animals, by testing them in healthy persons—by clinical observations, by records of cases, and so on; but whatever amount of knowledge may be thus arrived at, it can never be advantageous for medical treatment, until, as I have endeavored to show, we are first capable of recognising with exactitude the disease we investigate, and secondly, know its nature and natural progress. These steps must be preliminary to all advance in therapeutics, and that they have not hitherto been made so, is at once the explanation of past failure, and the indication for future success. The true promoters of therapeutics, consequently, are not those men who pass their lives in treating patients as well as they can from the results of pre-existing or present knowledge; they are not those who are constantly arranging the well-known opinions and assertions of former writers as to the effects of past treatment; but they are those who direct all their ener- gies to improving diagnosis, advancing physiology and pathology, and re-testing the action of doubtful remedies with all the advantage de- rived from our advanced knowledge. This conviction must force itself on the minds of all who seriously consider the subject, and, in truth, it is the one which renders every earnest and truthful student amongst us a physiological pathologist. The result is already obvious. We are gradually sweeping away the errors of empiricism, slowly clearing the ground for the erection of a more simple and solid temple of knowledge. This accomplished, we hope to accumulate, by laborious toil and research, * Beale's Archives of Medicine, vol. L, p. 209. TRUE FOUNDATIONS FOR MEDICAL PRACTICE. 351 materials for its foundation,—a work to which I think we are gradually approaching,—in the hope that, by patience and perseverance, a day will arrive when Medicine will be generally allowed to have approxi- mated towards, if it do not actually reach, the character of an exact science. The true principles, therefore, which should guide our efforts to advance therapeutics are— 1. That an empirical treatment derived from blind authority, and aa expectant treatment originating in an equally blind faith in nature, are both wrong. •1. That a knowledge of physiology and pathology is the real found- ation and necessary introduction to a correct study of therapeutics. 3. That a true experience can only have for its proper aim the deter- mination of how far the laws evolved during the advance of these sciences (physiology and pathology) can be made available for the cure of disease. In concluding this part of our lectures, I have only to express my conviction that any uncertainties as to the future existence of a scien- tific Medicine can only be removed by working Out in all its details the Molecular Theory of Organization. The histogenetic and histolytic trans- formations of the tissues, the various metamorphoses they undergo in the exercise of the nutritive and nervous functions, as well as the correla- tion and conservation of the dynamical, chemical, and vital forces of the economy, are the points now being determined by the physiologist. We are still waiting for the solution, by the organic chemist, of several inquiries necessary for our onward progress. But these accomplished, as it is hoped they soon will be, it must be recognised that all action and all function must be • essentially dependent on the formation and existence of the molecular constituents of the frame. Then, also, it will be seen that the agents which operate upon it, either from without or within. must be capable of being so prepared as to act on these minute particles, and it will be made apparent that one law will blend into a harmonious whole the kindred sciences of physiology, pathology, and therapeutics. In the meantime it follows from all that has preceded, that many of the principles which have hitherto guided us in the treatment of disease must be considerably modified. That medical practice has undergone a great revolution during the last twenty years, is a fact already so well established, that it can be no longer denied. Firmly believing that many of the changes which have been effected are permanent improve- ments in our art, and may be traced to the advance in the sciences on which that art is based, it will be our especial object in the succeeding pages to point out in what way more perfect principles have led to a better practice. Amid the multiplicity of conflicting statements, and t ic clashing of opposing systems, it will be our honest desire to sepa- rate what is known from what is unknown, and lay down such rules for treatment as both science and experience may alike confirm. SECTION IV. DISEASES OF THE NERVOUS SYSTEM. The diagnosis of nervous disorders is dependent on a kind of knowledge altogether different from that appertaining to the consideration of cutaneous, pulmonary, or cardiac affections. In these last, as we shall see, a direct appeal to the senses enables us to arrive at conclusions with tolerably accuracy. An arbitrary classification of skin diseases once established, with clear definitions, we have only to apply these to the appearances observed to ascertain the disorder. Once master the prac- tical difficulty of distinguishing with exactitude moist from dry rales— whether a murmur replace the first or second sound of the heart, and what is its position, and we possess a key which, with the aid of per- cussion, will frequently enable us to arrive at the certain diagnosis of pulmonary and cardiac affections. But with regard to nervous diseases. no such exactitude is attainable in the present state of the science or art of medicine. The encephalon is an aggregation of various parts, more or less connected together, the functions of which are by no means determined. In health these act in harmony, but in disease they are so irregularly disordered that while the action of one is excited, that of another may be perverted or annihilated. Then, again, we frequently observe that some of the most fatal nervous diseases, such as hydro- phobia, leave after death no lesion detectable by the most careful histological examination, whilst on other occasions tumors and extensive destruction of the cerebral mass may exist, without producing any symptoms whatever. And yet, notwithstanding the obvious difficulties which oppose themselves to exactitude of diagnosis of nervous diseases, careful observation, conjoined with a knowledge of physiology and patho- logy, will enable us to approximate closely towards, if not actually to reach, a correct opinion in the great majority of cases. The same circumstances render a pathological classification of nervous diseases impossible. Thus any one special lesion may produce the most remarkably different effects, according as it occurs rapidly or slowly; as it is single or multiple; as it is small or great in amount; as its nature is simple or compound; or as it affects different parts of the nervous mass. Thus the compound functional character of the brain alone, if disordered, may give rise to increase, perversion, or loss of three functions, viz., intelligence, sensation, and motion, each as different in its modes of manifestation and effects, as are the important functions of digestion, respiration, and secretion. Neither can we satisfactorily arrange nervous diseases in accordance with the symptoms which may be CEREBRAL AND SPINAL SOFTENINGS. 353 present, as these are so various and so complicated in different cases. This, however, is the method which has stamped its features on medical literature since the days of Hippocrates, and from which, in consequence, without anything more certain to offer, it is in the present state of medical science impossible to escape. What we, however, strenuously contend for, is the inconsistency in our nomenclature of applying to morbid lesions the same names as have long been recognised in a different sense as indicating groups of symptoms. Apoplexy, for instance, is not necessarily hemorrhage into the brain, nor does every hemorrhage produce apoplexy. If, then, we use admixed classification which seems to be the best now open to us, that is, one partly anatomi- cal, founded on altered structures, and partly physiological, founded on altered functions (that is, symptoms)—let us define accurately in all instances what we mean by the names employed. Thus we can use the terms congestion, softening, and suppuration of, or exudation, effusion, and hemorrhage into the brain and spinal cord, as we do when these lesions affect any other organs. But we should understand by apoplexy, loss of consciousness and voluntary motion, beginning at the brain; by epilepsy, paroxysmal loss of consciousness with convulsion; by spasm, increased tonic; and by convulsion, increased clonic contractions of the muscles; and by paralysis, loss of motor, or sensitive power of a part, etc. If we employ morbid lesions to designate the disease, we regard groups of symptoms as their effects. But if we use groups of symptoms to denominate the disease, then, however well we may observe these, we are often incapable of determining what are the structural changes on which they immediately depend. The key to the diagnosis of nervous diseases will be found in the general sketch we have given of the function of innervation (p. 137), and especially in the pathological laws which regulate diseased action of the nervous system; and to these we refer the reader (p. 148). The morbid anatomy of the nervous system will be found treated of in various parts of the work.* But there is one predominant lesion, which has lately had much light thrown upon it histologically, and which is so important in a diagnostic point of view, that we propose allluding to it, before entering on the consideration of individual nervous diseases. ON THE PATHOLOGY OF CEREBRAL AND SPINAL SOFT- ENINGS, AND ON THE NECESSITY OF EMPLOYING THE MICROSCOPE TO ASCERTAIN THEIR NATURE. The nature of cerebral and spinal softening has been much disputed. Some attribute it entirely to chronic or acute inflammation; others, while they acknowledge that softening is undoubtedly thus produced, are also of opinion that it may occasionally depend upon other causes. * Congestion of the cerebral vessels, pp. 148 to 151. Exudative softenings, pp. 167, 168. Albuminous degeneration, p. 248. Pigmentary degeneration, p. 263. Mineral degeneration, p. 271. 23 354 DISEASES OF THE NERVOUS SYSTEM. Thus softening has been considered a lesion sui generis, similar to what occurs in ataxic fever (Recamier), to gangrena senilis (Rostan, Aber- comby), to obliteration of the arteries (Bright, Carswell), or to a dimi- nution of nutrition (Delaberge, Monneret). It has also been referred to post-mortem maceration (Carswell, Paterson of Leith), and is undoubt- edly often produced by mechanical violence after death. The difficulty hitherto has been how to distinguish with precision one kind of soften- ing from another. From a careful analysis of numerous cases of cerebral softenings, I have arrived at the conclusion that they may originate in six ways. 1st, From exudation which is infiltrated among the elementary nervous structures; 2d, from a mechanical breaking up of these structures by hemorrhagic extravasations, whether in large masses or infiltrated in small isolated points; 3d, from fatty degeneration of the nerve cells, independent of exudation; 4th, from the mere imbibition of serum which loosens the connection between the nerve tubes and cells; 5th, from mechanical violence in exposing the nervous centres; and 6th, from putre- faction. 1st, Exudative or inflammatory softening always contains granules and granule cells, which are nume- rous according to the degree of soften- ing. The granules are for the most part seen coating the vessels (Figs. 148, 334, and 335), and the cells also may occasionally be seen there in various stages of development (Fig. 150). In the demonstrations that Fig. 4oi. are made under the microscope, they are frequently seen diffused among the tubes (Fig. 401), which, accord- ing to the severity and extent of the lesion, are easily separated from one another, or broken up in a variety of ways. When recent, the serum Fig. 402." Fig. 403. which accompanies the exudation is infiltrated into the nervous substance. Fig. 401. Structure of inflammatory exudative softening of the lumbar portion of the spinal cord, showing granule cells infiltrated among the nerve-tubes in a para- plegic individual.—(WedL) Fig. 402. Structure of a tubercular exudation in the cerebellum, composed of granules and tubercle corpuscles, with a few fragments of nerve-tubes. Fig. 403. Structure of the softened cerebellum, immediately external to the same tubercular mass, containing a larger number of fragments of the nerve-tubes, with numerous granular corpuscles. 250 diam. CEREBRAL AND SPINAL SOFTENINGS. 355 and may assist occasionally in producing softening, although for the most part it is rapidly absorbed. In chronic cases this form of soften- ing may be regarded in one sense as a fatty degeneration, although, when speaking of this last lesion, I have stated my reasons for consider- ing it as a transformation of the exudation, and not of the nervous sub- stance. (See p. 257.) Simple, tubercular, and cancerous exudations, alike cause cerebral or spinal softenings, as shown by the presence of the characters peculiar to each. Tubercular masses in the brain are generally surrounded by a layer of cerebral substance exhibiting all the characters of this form of softening (Fig. 403). Cancerous exudation into the brain is very rare (Fig. 302). 2d, Hemorrhagic softening.—When blood is extravasated with force into the cerebral structure, it breaks up the nerve-tubes of the part and coagulates. The coagulum then forms a solid mass, whilst the serum, more or less tinged with coloring matter, is infiltrated to a greater or less distance and absorbed. Under such circum- stances, the softened nervous tissue sur- rounding the clot presents fragments , of the nerve-tubes alone, which under the microscope frequently exhibit a peculiar tendency to form circular, oval, or irregularly-formed globules, with double outlines, as in Fig. 404. There are none of the granule cells so characteristicof an inflammatory soften- ing, although they may appear later, as the result of exudation from the cere- Fig. 404. bral vessels surrounding the clot. In such cases the greatest variation in the appearance of the nerve-tubes is observable, from a slight dimi- nution in their natural firmness and consistence, which renders them easily separable, or causes varicosities or swellings in them to be readily produced on pressure, up to a condition when they exhibit nothing but fragments and separate globules, as in Fig. 404. The colored cerebral softenings which are subsequently produced as a result of hemorrhage are owing to the transformations which go on in the coagulum itself. They assume a bright orange, brick red, yellow, fawn, or dirty brown color, and under the microscope are found to consist of hematine in various forms and tints. Thus the whole may be granular, or mingled with crystals of hematoidine or melanine; and the granules, granular masses, and celloid degenerations, may present numer- ous shades of orange, red, brown, black, etc. etc. (See Pigmentary Degeneration, p. 262, et seq.) 3d, True fatty softening.—This lesion, that is, a primary fatty Fig. 404. Structure of the softened cerebral substance, surrounding a recent clot of blood, showing the appearance assumed by the nerve-tubes when broken up, and softened by imbibition with serum.—See Apoplexy, case of Pitbladdo. 250 diam. 35G DISEASES OF THE NERVOUS SYSTEM. degeneration independent of exudation or hemorrhage, is one of the existence of which I was for a long time very doubtful. Careful investigation, how- ever,has satisfied me,that it does occasionally, though rarely, present itself, apparently as a consequence of obstruction of arteries. In this case the vessels are not coated necessarily with granular exudation, but the nerve-cells undergo the fatty degeneration primarily and are enlarged. The walls of many of them also are dissolved, leaving triangular or cres- centic-shaped granular masses between the nerve-tubes. This alteration is accompanied with diminution of the cerebral density, and Fig. 4057 the nerve-tubes are also easily separated and broken up, though not so readily, as in the last form of softening noticed. 4th, Serous or dropsical softening.—This kind of softening is due to imbibition of the serum, which is effused into the ventricles in cases of hydrocephalus and other diseases. Hence it is only found in the neigh- borhood of such effusions, and most commonly in the central portions of the brain, as in the white matter of the septum lucidum, fornix, etc. It is the white softening of morbid anatomists, and consists structurally of nothing but the cedematous normal elements of the parts, without any of the changes peculiar to the exudative, hemorrhagic, or true fatty softenings. The observations of Dr. Robert Paterson of Leith tend to show that the brain substance is very porous, and that if a slice of it is placed in water, it readily imbibed a considerable quantity, becoming at the same time more soft. Whether such softening ever occurs in the living body is very doubtful; it is most probably a post-mortem change. Sometimes serum is found to a considerable extent in the ventricles, without softening of the surrounding parts. The fluid apparently in such cases has not passed through the lining membrane of the ventricles. At other times this has occurred, and the softening so occasioned is found to be greatest near the central parts, and to diminish according to the distance from them. The causes which produce, and at others impede, post-mortem imbibition are unknown. 5th, Mecltanical softening.—I have frequently seen softenings occa- sioned in the brain, and more frequently still in the spinal cord, through crushing the nervous texture, after death, in various ways. Thus the saw or chisel may occasion mechanical softenings in the superficial parts of the brain, when the calvarium is being removed by inexperienced or unskilful operators. In France, where the hammer is used for this pur- pose, it is a frequent cause of superficial softenings. The spinal cord is especially liable to be injured, by slipping of the chisel or lever used in elevating the posterior spinous processes of the vertebrae. Portions of soft nervous tissue, such as the corpus striatum, have frequently had their Fig. 405. Structure of the softened pons varolii, in a case where the basilar artery was obstructed, showing true fatty degeneration of the nerve-cells, among somewhat softened and broken up nerve-tubes. See Cerebral Hemorrhage, case of Alexander Walker. 50 diam. CEREBRAL AND SPINAL SOFTENINGS. 357 texture reduced to a pulpy consistence by mere handling, or by constant application of the finger simply to ascertain whether it be softened or no. I have seen softenings exactly resembling such as may be occasioned by disease, produced in all these ways, and thus give rise to most erroneous conclusions. They are only to be distinguished by a microscopical ex- amination, and by a careful consideration of the symptoms observed during life, and of the causes which probably may have produced them after death. 6th, Putrefactive softening.—This may occur in warm weather, from the body having been examined long after death, or from accidental causes. Hence the necessity of always stating the number of hours after death that the examination is made. Such softenings are always diffused through considerable masses of cerebral texture, and may be recognised by this circumstance combined with an absence of all the signs which distinguish the other forms. Of these six kinds of softening found in the body after death, only the first three occur in the living subject, and give rise to symptoms, and of these three, the pure fatty degeneration, though frequently associated with the others, has been so seldom noticed, that we are to a great extent unacquainted with its symptoms as a special lesion. As regards the last three, they have been frequently confounded by morbid anatomists with the others, and all attributed to one cause. I think we are now enabled to distinguish accurately such as are the result of exudation from such as are not. From a careful analysis of 32 cases of softening of the nervouj centres, which I published in 1842-43,* it was shown that different symptoms were connected with exudative or inflammatory, from those which occurred in non-inflammatory softening. In 24 of these cases in which cerebral softening was observed, granular corpuscles were present in 18, whilst in 6 no traces of these bodies could be found. On analys- ing the symptoms of the 24 cases, a marked difference was found be- tween those resulting from the two lesions. Thus, in the cases where only inflammatory softening was present, well-marked symptoms invari- ably existed, such a loss of consciousness, preceded or followed by dul- ness of intellect, contraction and rigidity of the extremities, or paralysis. On the other hand, in the six cases of non-inflammatory softening, there was no paralysis or contraction, and no dulness or disturbance of the intellect. Again, in the four cases where b^h lesions were present, symptoms were always observed in the side of the body opposite to the seat of the inflammatory softening, but none existed in the opposite side in the non-inflammatory. An analysis of these 24 cases, therefore, leads me to the conclusion, that the two kinds of softening I have endeavored to establish are alike distinguishable, by their intimate structure, and by the symptoms accompanying them during life. Now all practical men agree in considering it a matter of extreme difficulty to reconcile, with any certainty, the morbid appearances found in the brain, with the symptoms observed during life. The future microscopic examination of the softening may serve to prevent much of the error that has hitherto been committed. For instance, softening of * Edinburgh Medical and Surgical Journal, Nos. 153, 155, and 157. 358 DISEASES OF THE NERVOUS SYSTEM. the fornix, septum lucidum, and central parts of the brain, may exist in two cases. To the naked eye they may be in every respect identical, and yet the microscope enables us to determine that the one contains granular corpuscles, whilst, in the other, not one of these bodies is to be found. It becomes evident, then, that previous to this distinction having been made, two different lesions were confounded together; and that a different train of symptoms should, under such circumstances, be occa- sioned, is only to be expected. Again, it has frequently excited surprise that, notwithstanding the existence of well-marked symptoms of soften- ing, nothing was to be discovered after death. Now I have demonstrated in several instances that, although to the naked sight no morbid lesion was apparent, still portions of brain might contain the same granular corpuscles as are to be seen in more apparent lesions; and that by con- sidering such parts diseased, all the symptoms might be explained ac- cording to the pathological laws I have previously referred to (p. 148, et seq.) By excluding these sources of error, therefore, and by distin- guishing the lesion dependent on inflammation from others which simulate it, we shall be enabled to obtain more exact data for future investigations. From the observations recorded, however, the two following propositions may, I think, be established. 1st, That pathologists have often con- founded softening dependent on disease during life, with softening occa- sioned by post-mortem changes or mechanical violence. 2d, That not- withstanding the most anxious search, and the existence during life of the most decided symptoms of softening, the organic disease, though really present, has frequently escaped observation. Proposition 1.—That pathologists have often confounded softening dependent on disease during life, with softening occasioned by post- mortem changes, or mechanical violence. With respect to this proposition it may be observed that, in many cases where no symptoms were present during life, extensive softening of the brain has been found after death. This is a well-known fact, and is one which tends in no small degree to throw confusion on the pathology of nervous diseases. Thus, in one case of a series I published in 1843,* there was extensive softening of the central portion of the brain, corpora striata, and optic thalami, which, however, contained no granular corpuscles. The symptoms attending these lesions were sudden insensi- bility and convulsions, which evidently depended on a capillary apoplexy that was also present. No paralysis or contraction existed. Four other cases were recorded, with more or less softening of the brain, without head symptoms, and without granular corpuscles in the softened portions. Now in all these five cases there was an extensive softening, the nature of which it was impossible for any one to distinguish positively, by unaided sight. In none of them did granular corpuscles exist, and in none did those symptoms occur which are peculiar to softenings pro- duced during life. In addition to these five cases there were four others, where, conjoined * Pathological and Histological Researches on Inflammation of the Nervous Centres. By the Author. Edinburgh, 1843. CEREBRAL AND SPINAL SOFTENINGS. 359 with an exudative softening producing particular symptoms, there was also a softening, occasioning no symptoms whatever, and containing no granule cells. The circumstances attendant on these nine cases, there- fore, must convince us that softenings produced mechanically, or by post-mortem changes, have frequently been mistaken for those occurring during life, and must necessarily be so, so long as unaided sight is made the sole means of forming a judgment with respect to their nature. A perusal of these cases must satisfy any one that pathologists have hitherto been confounding two distinct lesions, viz., a softening dependent on vital changes, and a softening dependent on mechanical or other causes. Proposition 2.—That notwithstanding the most anxious search, and the existence during life of the most decided symptoms of softening, the organic disease, though really present, has frequently escaped obser- vation. In the series of cases alluded to there are several which serve to establish this proposition, of which I may more especially refer to two. Case 1, a man had paralysis, with complete resolution of the limbs on the right side, and intense rigidity of those on the left. Death occurred in six hours. On dissection, a large coagulum of blood was discovered in the left hemisphere, thus explaining the paralysis on the right side. In the right hemisphere an old apoplectic cyst was found, and a number of small cavities, described by Dr. Sims as chronic softening undergoing a cure. Here, then, there was nothing acute, nothing to explain the intense rigidity. A microscopic examination demonstrated that these cavities contained numerous granular cor- puscles and granules, thus proving the existence of structural changes in the right lobe of the brain, and explaining the rigidity on the left side of the body. Case 2 was that of a man who entered the infirmary under Dr. Paterson, in 1842. All the symptoms of acute softening were present; paralysis of the left side, including rigidity and contraction of the left arm, dulness of intellect, and tonic spasms of the muscles of the mouth and neck. The right side was also affected in a slight degree. As the case excited considerable interest, great care was taken in examin- ing the brain after death. When the lateral ventricles were opened, it became a question whether the right corpus striatum was softened. Several persons applied their fingers and endeavored to ascertain the point. As the manual examination proceeded, the normal consistence of the part diminished, until at length it presented all the appearance of pultaceous softening. In this state it was shewn to Dr. Paterson, who naturally enough considered it to be the result of disease. I differed from him in opinion, first, because I had carefully observed the gradual increase of the softening in the manner alluded to; and secondly, because disease of the corpus striatum, in one side of the brain, could not have explained the well-marked symptoms which existed on both sides of the body. When the pons varolii was bisected, Dr. Peacock, who conducted the examination, conceived it to be 360 DISEASES OF THE NERVOUS SYSTEM. softened; others who examined it could perceive no difference in the texture; its color and consistence were unchanged. Reasoning from the symptoms, the lesion was very likely to exist. But how, it was argued, could a judgment be formed; we ought to reason from facts not theories ? Here, then, was an evident lesion of the corpus striatum which explained nothing, and a problematical lesion of the pons varolii which, however, did it exist, would satisfactorily account for the symp- toms. In this state of uncertainty the microscope was sent for, and I demonstrated and made evident to Drs. Paterson, Peacock, and all the students present, that the corpus striatum contained no granular corpuscles, whilst in the pons varolii they were very abundant. I have endeavored to describe what took place on this occasion, from which it must be evident that had not the microscope been appealed to, the right corpus striatum would have been pronounced softened, whilst the real lesion in the pons varolii might have escaped observa- tion. Under such circumstances this case would have added another to the inexplicable observations with which the records of nervous diseases abound. What renders these cases, and several others I could relate, so remarkable and satisfactory is, that they are not instances where the dissection was performed in a hurried manner, and by incompetent persons. On the contrary, from the particular symptoms connected with them during life, the post-mortem examination was in all con- ducted with extreme care. The physician who had charge of the case was present. The examinations were witnessed or conducted by my- self, in the presence of clerks and numerous students, and I may say that we were all in doubt until the microscope cleared up the difficulty. These cases, therefore, sufficiently demonstrate that the naked sight is positively unable to detect lesions, even although they are directly indi- cated by the symptoms, and carefully looked for by experienced morbid anatomists. If, then, the two propositions formerly stated have been satisfac- torily proved, and it is agreed that pathologists have been confounding vital with post-mortem softening, and overlooking the former, although undoubtedly present, it must be evident that many of the contradic- tions which have apparently existed in connection with the pathology of nervous diseases may be accounted for. It must also be clear that no confidence can be placed in the analysis of cases, however nume- rous, when the sources of error now indicated have not been carefully excluded. ACUTE HYDROCEPHALUS. Case 1.*—Acute Hydrocephalus—Recovery. History.—Janet Reid, set. 12—admitted June 12th 1850. About three weeks ago she fell down and struck the back of her head violently, but soon recovered, and remained well until two days ago, when febrile symptoms, with headache, occurred. The following morning these continued, and vomiting came on, with great restless- ness, and crying at night. Reported by Mr. E. S. Wason, Clinical Clerk. ACUTE HYDROCEPHALUS. 361 Symptoms on Admission.—On admission she is very drowsy, and starts occa- sionally in her sleep. When roused she is fretful and irritable, and complains of headache. The pupils are dilated, but contractile on exposure to a strong light; pulse 104, of good strength; skin hot; tongue covered with a white fur, and dry; no appetite; great thirst; bowels not open for two days. Urine, sp. gr. 1030, with phosphatic deposits. R Calomel, gr. iij; Puiv. Scammon. gr. v., Fiant Pulv. tales duo. Sumat unum statim, et alterum post horas tres.—Applicent. hirudines, iv. capiti. Progress of the Case.—June 13th.—Leeches bled well. Took both powders, and had an injection, which brought away one stool of a dark greenish color. Still complains of pains in the head, and general uneasiness when moved. But there has been no more vomiting, and there is no intolerance of light. Pupils natural; pulse 120, rather sharp; skin still hot and dry; continues drowsy, and fretful when moved; tongue white and moist.—Sumat Ext. Sennce, 3 ij, ex aqua, et repetatur post horas quatuor si opus sit. June 15th.—No headache and not so drowsy. June 2'ld.—Since last report has been gradually improving; the febrile symptoms have ceased, and she was dismissed quite well. Case 2.*—Acute Hydrocephalus in a Scrofulous Child—Recovery. History.—John M'Aulay, zet. 9, son of a servant—admitted July 5, 1855. This boy is of a scrofulous constitution, and was admitted into the Surgical Hospital, June 22d, for a scrofulous sore on the left ankle. Three days afterwards he was attacked with scarlatina, whieh ran a mild course, and from which he was convalescent on the 29th. June 30th, however, he complained of not having slept, vomited several times, and was very restless. July 1st, he refused to eat anything, and in the course of the day screamed violently several times. There was also cephalalgia, drowsiness, photophobia, and great irritation when roused. In this condition he remained until admitted into the Medical Clinical ward, the tendency to constipation having been counteracted by the administration of purgatives twice. Symptoms on Admission.—On admission, the face is pinched, and expressive of great irritability. He cries fretfully when touched or disturbed. The eyes are spasmodically closed, and he resists all attempts to open them; but when this is done, both pupils are seen to be dilated, and not movable on exposure to the light. On being left quiet, he turns away from the light, and^ relapses into a doze, interrupted by occasional moanings. Pulse slow and feeble, difficult to count from resistance of the child; skin and head of natural temperature. There is still a scrofulous ulcer on the left ankle, discharging pus of an offensive odor. Tongue furred; refuses food; bowels constipated; has no cough or pulmonary symptoms, and has never had strabismus, grinding of teeth, convulsion, or paralysis.—To have beef tea, milk, and nutrients, with § iij of sherry wine daily. 1} Pulv. Jalap, gr. v.; Hydrarg. Chlorid. gr. ij; ft. pulv. hora somni sumeiidus. Progress of the Case.—July 6th.—At seven a.m. passed a copious, dark, offensive stool. Has been persuaded to take a little milk, but refuses other nourish- ment. Still fretful and irrritable, but the nurse says he did not scream or toss about so much during the night. Pulse 64, weak. Otherwise the same. July 11th.— Since last report the general irritability has somewhat diminished, and last night he slept well. Has gradually been induced to take more nourishment. Does not scream now, but moans occasionally, and tosses about until exhaustion produces sleep. Now and then he puts his hand to the forehead, and says he feels pain there. His sight is occasionally dim, but at other times he sees well. Cannot sustain any train of thought or conversation long. Still constipation, which is relieved every third day with the powder of calomel and jalap. July 20th.—There has been gradual improvement on the whole, although much variation from day to day. Some nights are more restless than others, with occasional screaming. He still puts his hand to the head, which is sometimes, he says, " sore." The pulse has varied from 60 to 80. The appetite has improved, and he takes more nourish- ment. Sight and memory more perfect. August 3d.—Has been occasionally screaming a good deal at night, but is now much better, and walks about on crutches, the scrofulous sore on the ankle being no better. August 8th.—It having been stated that he was affected with worms, he has taken some doses of the etherial extract of the Male Shield Fern, followed by purgatives. These have produced * Reported by Mr. Robert Byers, Clinical Clerk. 362 DISEASES OP THE NERVOUS SYSTEM. several stools, but no worms. His appetite and general health have now been greatly restored. There is no pain in the head, or restlessness at night, and he was sent back to the surgical wards to have his ulcer treated. Commentary.—In the two preceding cases we have good examples of that congestive and irritative state of the brain, which occurring in children has been regarded as indicative of acute hydrocephalus. Whether in either of them the disease had proceeded to actual effusion, it is of course difficult to determine, although the pain in the head and restlessness passing into somnolence render this probable. In the first case, where the child was tolerably healthy, febrile phenomena with ex- citement were more pronounced than in the second scrofulous case, in which exhaustion was evident from the first. Hence why a few leeches and laxatives constituted the treatment in the girl Reid, although, it will be observed, that their employment produced no marked improvement in the symptoms, the pulse on the following day being 120, sharp, the skin hot and dry, with a continuance of the drowsiness. Notwithstand- ing, no further antiphlogistic remedies were persisted in, and two days subsequently the patient. became convalescent. In the second case an opposite plan of treatment was practised from the first. Here the puke was slow and feeble, the symptoms were indicative of exhaustion, and this child not only had a scrofulous sore, but had recently recovered from an attack of scarlatina. Nutrients with wine, therefore, were persever- ingly pressed upon the patient, notwithstanding the deficient appetite and nausea, with the effect of ultimately establishing a recovery. Case III.*—Acute Hydrocephalus—Phthisis Pulmonalis—Death— Effusion into the Lateral Ventricles—Non-Inflammatory softening of the central parts of the Brain—Meningitis at the base of Cra- nium—General Tuberculosis. History.—Mary Ann Flynn, set. 6—admitted June 26, 1845. She is an intelli- gent child, of scrofulous and cachectic appearance, and greatly emaciated. From her own statement she had influenza a year ago, and has had a cough ever since. Her diet has always been very poor, chiefly consisting of potatoes without any milk or animal food. Latterly she has experienced pain in the head, has been feverish and restless at night, and yesterday she vomited several times. Symptoms on Admission.—On admission she complains of headache, pain in tie back, great thirst, nausea, and cough. The pain in the head is felt over the fore- head, sometimes extending to the entire head; is constant but not severe at present. She has also slight pains in the back, not increased on pressure. Her intellectual powers are for her age unusually good; pupils and eyeballs natural; never had fits or other derangement of the nervous system. She has no appetite, refuses all food, but constantly desires drink; tongue covered with a whitish fur; mouth, dry. She has not vomited since admission, but complains of distressing nausea; abdomen feels natural; had diarrhoea of light yellow fluid stools two days ago, which has now ceased; has frequent prolonged cough, not accompanied by much expectoration. On percussing the chest, there is comparative dulness under the right clavicle, and on auscultation over this part, a loud moist rattle accom- panies the inspiration, extending down to the third rib. Here also there is broncho- phony. Similar signs exist on the right side posteriorly, at the apex of lung, and over the rest of the chest there is great harshness with inspiration, and prolonged expiration with occasional sibilation. Respirations are 26 in the minute; pulse 150, small and somewhat hard; heart sounds rapid, but normal in character; skin hot, covered with perspiration; head unusually warm.—Applicent. kirudines iv. temporibus—Habeat Vini Ipecac. § ss. * Reported by Mr. D. P. Morris, Clinical Clerk. ACUTE HYDROCEPHALUS. 363 Progress of the Case.—June 21th.—The emetic operated powerfully; nausea removed; headache diminished; otherwise the same. July 2d.—Since the 28th there has been frequent vomiting, for which naphtha, hydrocyanic acid, and other remedies, have been given without benefit. Little food has been taken. Loud gurgling audible under right clavicle; constant cough, with purulent expectoration. The surface is pale, and she cannot be spoken to or touched without causing cries and moaning. Bowels open; stools natural. There has been occasional diarrhoea, which has been checked by chalk mixture. Constant pains in the head, with great restlessness at night. Pupils slightly dilated; pulse 100, of good strength. Abradatur Capillitium et Applicet. Emp. Lytto2. Milk diet with beef tea and wine in small quantities. July 1th.—Has continued much the same since last report, the vomiting being considerably less frequent however. Last night it is reported she was comatose, and could not be roused, and that convergent strabismus of the left eye was undoubtedly present. To-day she is lying on the right side, the knees drawn up to the abdomen ; the face pale; surface cool; respiration easy. She does not answer questions or protrude her tongue when desired, although her eyes and look are intelligent. No paralysis. Metallic resonance when she speaks or cries under right clavicle. Pulse 104, of good strength. Habeat Calomel, gr. ij, tertid qudgue hord. July 12th.—There has been alternate looseness and constipation of the bowels, the stools being of a spinach color. Sometimes better, at others' com- plaining of great pain in the head. The expression of countenance is now worn and haggard, with evident anxiety; eye and mind still peculiarly, and even painfully intelligent. No convulsion or paralysis, but great restlessness occasionally at night. At other times she sleeps well. Pulse is more frequent and weak, generally about 150 a minute. Omit. Pulv. Calomel. Habeat Vini, §ij, secundd qudque hord. July 15th.—Has been gradually sinking since last report. Pulse 180, feeble. Still intelligent, and answers questions. Died at five p.m., from exhaustion, without pre- vious coma, strabismus, convulsions, rigidity, or paralysis. Sectio Cadaveris.—Forty-three hours after death. Body greatly emaciated. Head.—On removing the dura mater from the superior surface of the hemi- spheres, the arachnoid covering them was found unusually dry, and the pia mater somewhat pale. On stripping the membranes from the convolutions, and holding them up before the light, they could be seen to be sprinkled at irregular distances with minute white hard points, having the appearance of tubercle, deposited in the sub-arachnoid tissue. The giandulae Pacchioni could easily be distinguished from them by their situation, softer consistence, and larger size. On removing slices from the hemispheres, fluctuation of fluid in the ventricles could readily be felt below. A puncture was cautiously made in the roof of the left lateral ventricle, and ^iiiss of colorless serum were removed with a pipette. On declining the head towards the left side, §j more fluid was removed, which had evidently passed from the right ventricle into the left through the foramen of Monro. This last portion was turbid, and contained small floating fragments of lymph. On opening the right ventricle it was collapsed. The foramen of Monro was the size of a large pea. The fornix, internal walls of the ventricle and cerebral portions in the neighbor- hood of the ventricles were of pulpy consistence, but of their normal color. On removing the brain from the cranium, the pons varolii, medulla oblongata, and corpora albicantia, were seen to be covered with a layer of pale gelatinous lymph, one-eighth of an inch in thickness. This layer only extended to the medulla oblongata inferiorly, where it passed through the foramen magnum, as was proved by careful examination of the spinal cord, which was healthy throughout. The third and fourth ventricles of the brain were enlarged, and distended with serum. The left lateral ventricle was also enlarged, especially its posterior and inferior cornua. The enlargement of the right lateral ventricle was confined principally to the anterior cornu. Chest.—Pleura? on right side sprinkled with miliary tubercle, situated below the serous surface. Both lungs studded throughout with hard miliary tubercle, of a grey color; in some places, however, it was yellow and soft. The intervening pulmonary tissue was of a bright red color, engorged, but pervious to air. In the superior lobe of right lung the tubercles were closely aggregated together, and con- tained numerous anfractuous cavities varying in size. Some were lined by a distinct 364 diseases or the nervous system. membrane, and all were filled with scrofulous pus. Heart and vessels healthy. The bronchial glands enlarged from infiltration of yellow cheesy tubercle, mixed with pigmentary deposit. Abdomen.—Liver of natural size. Gall-ducts and gall-bladder distended with fluid green bile. Kidneys healthy in size and general structure, but the cortical substance sprinkled over with minute grains of tubercle. Stomach healthy. The ilium was the seat of tubercular ulceration throughout, situated principally in the aggregate glands. Large intestines healthy. Mesenteric and lumbar glands for the most part enlarged in consequence of tubercular infiltration. Spleen throughout studded with yellow cheesy tubercle in granules varying in size from a pin's head to that of a pea. Peritoneum here and there dotted over with hard miliary tubercle deposited, however, below the serous membrane. Microscopic Examination.—The pale gelatinous lymph at the base of the brain was principally composed of molecular matter, in which a few granule cells might here and there be detected. The turbid fluid at the floor of the ventricles contained epithelium cells, some of which were undergoing the fatty degeneration. The white cerebral softening contained no granules nor granule cells. The hard grey and soft yellow tubercles in various parts of the body were carefully examined, and were found to present their usual characters (Figs. 157, 161). Commentary.—This is a well-characterised case of acute hydrocephalus in a child also affected with general tuberculosis. From the first it was certain that it would be fatal, for in addition to the cerebral lesion we had to do with an advanced phthisical condition. The appearances after death are strictly in accordance with all the symptoms which were care- fully observed during life. Her mind throughout was unaffected, except when occasional drowsiness or coma prevailed, and the circumference of the hemisphere was normal, while the lesions observed were confined to the ventricles and base of the cerebrum. Then there was no paralysis or convulsion, and the softening of the central parts was proved to be serous. The pain, irritation, stupor, and other symptoms, are readily explicable by the tubercular meningitis and gradual distension of the ventricles with fluid. The treatment was nutritive, and in obedience to the prac- tice of twenty years ago, an emetic, a few leeches on the head, and small doses of calomel were given. They were of no benefit, and need never be employed. The nature of acute hydrocephalus has been keenly disputed, and, whether it be inflammatory or non-inflammatory, and should be treated with antiphlogistics or nutrients, will be found to be discussed at great length in systematic works and numerous monographs.* The fact is, that the group of symptoms indicating the occurrence of water in the brain is altogether insufficient to prove the existence of this morbid pro- duct in acute cases. What we observe are symptoms of excitement, gradually passing into those of depression, occasionally accompanied with paroxysms of pain, restlessness, and screaming, alternating with drowsi- ness, exhaustion, and coma. The sesymptoms are common to various lesions of the brain, and may be the result of mere congestion, or of this state terminating in effusion and frequently in exudation. Hence why sometimes after death we find no lesion whatever; at others more or less distension of the ventricles with serum, and very commonly in addition exudation at the base of the cranium. In every case the symp- toms are referable not so much to the one or the other of these lesions, as to something which they all have in common, and this undoubtedly is * See the author's article on Hydrocephalus, in the Library of Medicine, vol. ii. London, 1840. ACUTE HYDROCEPHALUS. 365 more or less pressure on various portions of the brain, causing first irri- tation and then perversion of function, or so operating as to excite some parts and to depress others. In the great majority of cases the fluid dis- tending the ventricles is more allied to the dropsies than to the exuda- tions. Nay, even when lymph is thrown out at the base of the brain, the amount of serum in the ventricles is altogether disproportioned to the quantity of coagulated fibrin deposited. Hence I am disposed to think that, even when evidence of so-called inflammation does exist, as in Case III., still the fluid which distends the ventricles is owing to a mechanical obstruction of the vessels, causing dropsical effusion. As to the central white softening so commonly found in hydrocephalic cases, it is, in the vast majority of instances, a post-mortem appearance, caused by mechani- cal imbibition of the serum into the porous substance of the white tubular structure of the brain. I have seen this softening most extensive in cases where, immediately before death, the transmitting functions of the white central parts were perfect; and the fact that no relation exists between the symptoms during life and such softening after death has been noticed by numerous observers. . In a special work on this subject (London : 1843), Dr. Risdon Bennett, looking to the scrofulous character of the children usually affected with this disease, refers its nature to " vital changes in the brain, chiefly in the central white parts, of the character probably of tubercular degeneration,—and that softening, effusion into the ventricles, and meningitis, are all consequences of antecedent alterations of nutri- tion "—Pp. 148-49). This view, which contains the general truth, may, I think, now be more specifically stated as follows:—All circumstances, including scrofula, which weaken the general nutrition of the economy, tend to occasion languor and obstruction of the cerebral circulation. This defective nutrition is, in young children, especially liable to occasion congestions within the cranium, causing effusions and exudations, either simple or tubercular, and as a mechanical result of such effusion, those softenings so frequently found after death. Such appears to me the true pathology of acute hydrocephalus, including the " hydrocephaloid dis- ease " of Dr. Marshall Hall. In the treatment of this disease much stress has been laid by prac- titioners on the question, as to whether in any given case the symptoms are or are not dependent on inflammation, and if so, what may be the character, seat, and stage of the inflammation. If the disease be inflam- matory, blood-letting, with antiphlogistics and calomel, has been enjoined. When, on the other hand, it arises from diarrhoea, or after exhaustive diseases, an opposite line of treatment has been the rule. The profession cannot be too grateful to Dr. Marshall Hall for clearly pointing out how all the symptoms of hydrocephalus frequently arise in children after long- continued diarrhoea, febrile eruptions, or other exhaustive causes, and how they may frequently be restored under such circumstances by nu- trients and stimulants. But it may now be asked whether, in fact, we possess the means of clearly distinguishing the inflammatory from the non-inflammatory forms, and whether, if we did, we are justified in treat- ing the former by antiphlogistic remedies ? In reply to these questions, I would observe, in the first place, that all authors are agreed as to the difficulty of separating acute hydrocephalus 366 DISEASES OF THE NERVOUS SYSTEM. from remittent fever, and no one, so far as I am aware, has ever pretended that he could point out with exactitude the symptoms which distinguish cases in which there are, and those in which there are not, exudations of lymph within the cranium. After the most careful examination of many cases, both during life and after death, I feel satisfied that, conjoined with exactly the same train of symptoms, we may sometimes find only effusion of serum in the ventricles, with white softening, and at others more or less meningitis of the base. Again, I also feel satisfied that this meningitis, as proved, after death by the existence of layers of lymph, so far from indicating a so-called sthenic constitution in children, much more frequently occurs in scrofulous and weak children. Of this, Case III. is an example, where with phthisis and general tuberculosis, there was found conjoined with effusion into the ventricles, inflammatory ex- udation at the base of the cranium. The distinctions, therefore, hitherto so much dwelt upon, of two distinct forms—an inflammatory and a non- inflammatory—as guides of treatment, have no real existence, and are opposed to all positive research, as well as to a large experience in the observation and treatment of individual cases. When, in addition, it is considered that all the symptoms of acute hydrocephalus are referable to more or less pressure on different parts of the brain; that this pressure may be occasioned by congestion, effusion, or exudation ; and that we have no means of determining which or how much of each is present in any individual case, it must, I think, be certain that it is impossible in the vast majority of cases, and highly doubtful in all, to determine the existence of meningitis or cerebritis as a concomitant of acute hydro- cephalus. Lastly, the symptoms of the " hydrocephaloid disease," so well described by Dr. Marshall Hall, in which all the phenomena of hydrocephalus occur, and which are only distinguishable by the circum- stance that they originate from exhaustive causes, should alone make us pause before we have recourse to a lowering system of practice. But supposing we had the power to detect in any given case the occurrence of active exudation going on within the cranium, should we even then be justified in having recourse to blood-letting, general or local ? The considerations we have previously entered into (p. 268, et seq.)—first, as to the incompetency of this remedy (and of antiphlogistics generally) to meet the end in view ; and, secondly, as to the fact that we can only reach the circulation within the cranium by influencing the force of the heart (p. 148, et seq.)—are sufficient answers to this question. It follows, then, that the uncertainty of diagnosis, as well as the evil ef- fects likely to result from a lowering practice in these cases which almost always occur in weak children, are not only opposed to it, but perhaps sufficiently explain the acknowledged great mortality of the disease. For the like reasons the use of calomel to cause absorption of matters, whose existence we have no means of detecting, appears equally unreasonable, even supposing it had been proved to possess an absorbing power, which it certainly has not. On the other hand, the two first eases we have recorded are examples of what may be done by an opposite plan of treatment in acute hydro- cephalus, and in the third case, we believe the practice followed to have been the only warrantable one in the desperate and necessary fatal cir- cumstances. It bore reference to improving the general constitution and CEREBRAL MENINGITIS. 367 nutritive powers of the patient, which in all cases connected with a scrofulous habit are the indications to be more or less energetically fol- lowed according to the severity and duration of the disease. The calo- mel given as an alterative utterly failed. CEREBRAL MENINGITIS. Case IV.*__General Acute Meningitis supervening on Pleuro-Pneumonia. History.—David Murray, set. 43, a coal-heaver—admitted January 18, 1854. He has been an intemperate man, and a week previous to admission was seen by one of the pupils to be affected by delirium tremens. He now says, that on the 13th (which was the first day of thaw after frost and snow) he was much exposed to the weather while at work, but felt no ill effects until the morning of the loth at four o'clock, when he awoke very sick, and vomited several times. He kept his bed, feeling feverish, and in the afternoon began to cough. On the morning of the 16th he experienced a sharp pain in the right chest, about three inches below the nipple, which was increased by coughing and inspiring deeply, and prevented bis lying on that side. Has had no rigor nor headache. Symptoms on Admission.—On admission, respiration is impeded by interrupted inspirations whieh give pain. Over the lower half of the right lung posteriorly, there is marked dulness on percussion, loud crepitation on inspiration, and broncho- phony. The sputa are scanty, consisting of gelatinous matter, with rusty brown patches. No dyspnoea. Pulse 120, strong and full; skin hot and dry; tongue dry, furred, and fissured; great thirst; no appetite ; bowels open. Has no headache at present, but says he is restless at night, and sleeps badly. Other functions normal. To have one-third of a grain of tartrate of antimony in solution every two hours. Progress of the C.\.s::.—January 22d.—Since last report the pneumonia has followed its usual course.—(See Pneumonia.) On the 20th crepitation had dis- appeared, but has returned to-day. Yesterday evening was ordered a diuretic draught, containing Sp. JElher. Nit. 3 j. The pulse 130, weak, and at the visit his replies to questions were a little confused. January 23d.—Yesterday afternoon he was observed to mutter incoherently, but remained quiet until eight p.m., when he became violently delirious. He had a very wild and fierce expression of eye and countenance, insisted on getting up, would not be controlled, and struggled violently with those who endeavored to restrain him. He spoke little, but made incoherent noises. The pupils were much dilated ; the pulse very rapid and weak. The head was shaved, and constant cold applied. Prostration, however, coming on, wine and stimulants were given freely. He continued now and then to struggle violently; strabismus was apparent latterly. Died exhausted at five o'clock a.m. this morning. Sectio Cadaveris.— Thirty-one hours after death. Body greatly emaciated. Head.—On removing the skull-cap, the dura mater presented a uniform yellowish tint, dependent on a recent exudation below it. On removal, the subarachnoid tissue was infiltrated with a soft exudation, which covered the entire surface of both hemispheres, and of the cerebellum. It was as abundant at the base as on the supe- rior surface of the brain. On cutting into the cerebral substance, it was observed that the yellow exudation accompanied the inflexions of the pia mater between the convolutions. The lateral ventricles contained § iss of turbid serum. The lining walls of the ventricles were a little congested; the choroid plexuses healthy. The septum lucidum rather soft, but the other portions of the brain normal. Thorax.—Three lower fourths of the right lung presented the characters of grey hepatization posteriorly. The anterior surfaces were healthy. The pleurae covering this lung were partially adherent, with some shreds of recent lymph. Other thoracic org.ms healthy. Abdomen.—The liver enlarged, weighing 6 lbs. 4 oz., of pale color, and soft. The spleen also soft and pulpy. Other abdominal organs healthy. Microscopic Examination.—The exudation poured out in the subarachnoid * Reported by Mr. Robert Bird, Clinical Clerk. 368 DISEASES OF THE NERVOUS SYSTEM. cavity had everywhere undergone the transformation into pus. The turbid fluid in the lateral ventricles also contained some pus, with a few epithelial cells. The cerebral tissue was healthy. The liver cells contained an unusual amount of fatty granules. The pneumonic portion of the right lung was infiltrated with fluid mole- cular matter and pus corpuscles, most of which were more or less collapsed, and all of them very granular. The whole evidently in a state of disintegration. Commentary.—In this man, who was intemperate, and laboring under pneumonia, which was progressing favorably, there supervened at noon on the seventh day of the disease a little confusion in his ideas, which in the course of the afternoon passed into violent delirium, caus- ing strabismus and dilated pupils. At night he became comatose, and died at five o'clock next morning. At the commencement of the pneu- monia he had vomited, a symptom perhaps referable in him to cerebral irritation, a condition which the febrile state he was subsequently thrown into, however, did not appear to augment in any unusual degree. On examining the head after death, the subarachnoid cavity and involutions of the pia mater over the whole surface of the brain were loaded with purulent matter, and § iss of turbid serum was effused into the lateral ventricles. This, therefore, was an instance of very rapid death from meningitis, a result partly attributable to his previous intemperate habits, and partly to the circumstance that the disease appeared at a time when he was already much exhausted by the pneumonic attack. In this, as in Case III., it is observable that the occurrence of extensive exudation is in no way incompatible with depression of the bodily powers, a fact alto- gether opposed to tho supposed connection between inflammation and a sthenic state of the constitution. In fact, the extent as well as the fatality of the cerebral disease is probably to be attributed to the ex- haustion of the vital powers at the time of its occurrence. The pneumonia went through its usual progress, and on the day when the meningitis commenced, the returning crepitation was audible. On examination after death, the whole pulmonary exudation was found softened and converted into pus, which was already undergoing rapid disintegration. (See Pneumonia.) i Case V.*—Acute Meningitis at the Base of Brain—Serous Effusion into the Ventricles, with white softening of cerebral substance—Phthisis. History.—Helen Walker, set. 21, a servant—admitted July 4, 1853. She has for some years been subject to cough and dyspnoea, but nays she never had any serious illness until eleven days ago. She then experienced rigor, pain in the head, thirst, and other febrile symptoms. The headache has been variable in intensity, being sometimes slight, at others very severe. Symptoms on Admission.—On admission, she appears to be very weak and languid. Complains of severe frontal headache which is increased towards night. The eyes are dull and heavy; pupils unaffected. No muscae volitantes, tinnitus aurium, or vertigo. Is quite conscious, but has a tendency to stupor. The febrile symptoms have now for the most part disappeared. No thirst ; appetite impaired; tongue furred; pulse 84, soft. On examination of the chest, all the signs of phthisis, with cavities in both lungs, were detected. The other functions are normal. £he requested to have an emetic, which had previously relieved her, and one of ipecacu- anha and sulphate of zinc was given. Progress of the Case.—July 5th.—The emetic has not produced the same * Reported by Mr. G. C. Pirrie, Clinical Clerk. CEREBRAL MENINGITIS. 369 relief as formerly. Headache continues. In other respects the same. Six leeches to be applied to the temples. July 6th.—Last night wandering of the mind, with slight delirium. To-day, great depression, and stupor. As the bowels have not been relieved, to have a drop of croton oil, on sugar, to be followed by an enema, if necessary. Head to be shaved, and cold applied. Beef tea and nutrients. July 1th. —Last night great incoherence of mind, with raving. To-day at visit, still mutter- ing. Eyes are heavy; pupils contracted; tongue moist and white. Takes no nourishment; bowels open; pulse 120, regular, but weak. July 8th.—No change. Coma coming on. A blister to be applied to the occiput. July 9th.—Coma "with occasional low muttering delirium; picking at the bed-clothes; pulse almost imper- ceptible. Died on the morning of the 10th. Sectio Cadaveris.—Thirty-six hours after death. Body thin but not much emaciated. Head.—The arachnoid surfaces were very dry. The lateral ventricles contained about 11\ of slightly turbid serum. The walls of the ventricles and central white portions of the brain in their neighborhood were pultaceous, and easily broke down under a stream of water, presenting a rough surface, and on section a ragged edge but retaining their natural color. At the base of the brain, the crura cerebri are surrounded with soft yehow exudation, which is situated in the subarachnoid cavity and extends to the thalami optici, and slightly into the locus perforatus posticus! No tubercle can be seen in the meninges, and about 5 ij of serum were collected in occipital depressions after removal of the brain. Chest.—Both lungs were infiltrated with tubercle, especially the upper lobes. A cavity the size of a hazel-nut at the summit of left lung, and there were several in the upper lobe of right lung, communicating with one another. Abdomen.—Abdominal organs healthy. Microscopic Examination.—In the slightly turbid fluid of the ventricles were several epithelial cells from the choroid plexuses, undergoing the fatty degeneration. the pultaceous white softening surrounding the ventricles contained no granule cells or masses, and consisted of the tubes, easily broken down between glasses, presenting numerous large varicosities, circles with double lmes, etc. (Fig. 404). The exudation at the base was chiefly molecular, with here and there traces of pus. Commentary.—This case is in many respects like those formerly given under the head of acute hydrocephalus, and serves to illustrate the occurrence of acute meningitis with serous effusion, in a phthisical and exhausted subject. In this, as in the instances referred to, the leeches applied to the temples, with a view of relieving the headache, were of no benefit whatever, even temporarily. The day after their application all the symptoms and weakness were more pronounced ; in other words, the disease proceeded onwards towards the fatal termination. The structure of the exudation at the base of the cranium, and the incipient fatty de- generation in the serum of the ventricle.?, indicate that these lesions were of much longer standing than might have been supposed from a consid- eration merely of the symptoms of the case. Case VI.*—Acute Meningitis at the base of the Brain—Effusion of Serum into the Lateral Ventricles—Effete Tubercle in the Pons Varolii and Lungs. iR.HlSTr°rRTTJ°lhn Robertson> **• 35, a discharged soldier-admitted June 25, 1800. ne nas been of intemperate habits, and latterly, owing to poverty, has had hP?rf7JTP ?CXa?,d b6en ^sufficiently clothed. On the 13th he first experienced ™T V 1^ l^P'01113- 0n the 21st there was vomiting, with cough and expectoration, and on the 23d great restlessness and delirium at night. These symp- toms have continued ever since. He ^p7nTt,r A™0*--l0n admission he is in a state of great prostration. He lies quietly on his back, frequently talking incoherently, but is easily roused 24 * Reported by Mr. David Christison, Clinical Clerk. 370 DISEASES OF THE NERVOUS SYSTEM. when spoken to, and then answers questions sensibly. Countenance pale; eyes suffused; pupils rather contracted. He has no pain anywhere. His hands and arms are in a constant state of tremor, the former engaged in clutching the bed- clothes. Evacuations normal, not involuntary; tongue white and dry; deglutition difficult; chest everywhere resonant; expiration prolonged and harsh; little cough at present, and no expectoration ; pulse 64, feeble. Has been treated before admis- sion with calomel and antimonials. To have § iij of whisky daily with nutrients. R Sp. ^Ether. ML § ss ; Mist. Scilla;, 3 iiiss ; Aquce, ?jss. M. Sumat |ss quartd qud'jue hord. Head to be shaved and a blister applied. Progress of the Case.—June 26th.—Passed a restless night, with considerable delirium. To-day is no better. Moist rales audible at the base of lungs posteriorly. Weakness increasing. To have nutrients. June 21th.—Has refused all kinds of food and drink. Coma is now coming on. The extremities are cold; face livid; respiration laborious ; pulse 60, can scarcely be felt. The urine has been drawn off by catheter, and is quite normal. Bowels not open for two days. R. Ammon. Carb. gr. xviii. ; Mist. Camph. § iv; Solve. Sumat § ss quartd juaque hord. June 28th. —Became gradually weaker, and expired at four o'clock this morning. Sectio Cadaveris.— Twenty-four hours after death. Body somewhat emaciated. Head.—The convolutions on the surface of the cerebral hemispheres were some- what flattened, but not preternaturally dry. The substance of the brain was normal. The lateral ventricles distended with turbid serum, slightly tinged with blood, to the extent of § ij. Central substance of brain healthy. The subarachnoid tissue at the base everywhere infiltrated with recent coagulated lymph. In the substance of the pons varolii was a tubercular mass, the size of a pea, firm externally, soft towards the centre, and surrounded by a zone of congested vessels. The membranes covering the hemispheres, and other portions of the brain, healthy. Thorax.—Heart healthy. Pleura? on both sides adherent by chronic bands of lymph, especially at the apices of the lungs. Here both lungs were indurated and puckered, and contained several cretaceous and calcareous concretions. Their an- terior margins were emphysematous, and the posterior and inferior portions engorged, and the bronchi more or less filled with purulent mucus. Here and there, scattered throughout the inferior portions of both lungs were masses of old tubercle converted into calcareous matter, and varying in size from a barley-corn to that of a cherry-stone. Abdomen.—Abdominal organs healthy. Microscopic Examination.—The turbid serum in the lateral ventricles con- tained numerous granule cells, and a few blood corpuscles. The lymph at the base of the brain was molecular, with here and there masses of pus corpuscles in a state of disintegration. The cerebral substance around the tubercular mass in the pons varolii was healthy. Commentary.—In this case prostration was so marked that stimu- lants and nutrients were given on his admission, but without the effect of overcoming his exhaustion. It is to be observed, that although formerly of a tuberculous constitution, which had left traces of its existence, both in the brain and lungs, he had overcome this to such a degree that on exposure once again to exhausting causes, a simple or inflammatory rather than a tubercular exudation was the result. The structure of the exudation at the base of the cranium, and the granule cells in the serous fluid of the ventricles, indicated that the lesion was already somewhat chronic. In this, as well as the preceding case, it appears to me that the original headache and fever indicated the period of congestion and exudation, that vomiting pointed to commencing, and stupor to more intense pressure from the subsequent effusion. The seat of meningitis is the so-called subarachnoid cavity, in which there is a quantity of loose areolar tissue, richly furnished with.blood- vessels. It generally results that the exudation poured into this cavity, CEREBRAL MENINGITIS. 371 instead of undergoing the transformation into fibres, which usually occurs on serous surfaces, follows the law which regulates its passage into pus. Hence I have ascertained that what is generally called a recent layer of coatmlable lymph, covering the convolutions in meningitis, is, in point of fact, a layer of pus. That the exudation should not readily be poured out into the cavity of the arachnoid is explicable by the circumstance, that the solid and unyielding walls of the cranium would oppose any tendency to the enlargement of that space. Indeed, the greater the amount of exudation or effusion, especially in the deeper parts of the brain, the more would the two layers of the arachnoid be compressed together, and hence arises the dryness of this membrane in meningitis with effusion into the ventricles. The exudation in acute meningitis will be found to consist princi- pally of pus corpuscles, presenting an unusually molecular character, and ^sociated with numerous loose molecules and granules. In the chronic forms the pus corpuscles are seen to be broken down, and the whole is reduced to an amorphous granular mass, more or less mingled with fat granules. The blood-vessels, also, whieh enter into this mass may fre- quently be seen undergoing the fatty degeneration. When the ventricles are the seats of exudation, there are generally in the fluid epithelial cells of a globular form, which present various appearances according as they are swollen through endosmose, or have undergone the fatty degeneration and become granular cells. I have also noticed a great variety of changes in the villi of the choroid plexus under such circumstances. Occasion- ally their epithelial coating is much increased in thickness, and at other times is raised up in the form of small bullae, being probably the inci- pient stage of simple cystic formation. They frequently also contain a greater or less number of the amyloid bodies represented Fig. 392, the connection of which with active disease in the ventricles, however, has not yet been demonstrated. As to the diagnosis, notwithstanding the efforts which have been made to distinguish meningitis of the convolutions from that of the base, or either of these from a simple effusion into the ventricles, I have in vain sought for any precise symptoms which could be relied on as indicative of the situation of the disease. Pain in the head, vomiting, drowsiness, and coma, causing slow and subsequently rapid pulse, succeeded by more or less jactitation and convulsion before death, are the leading symptoms. The gradual mode of invasion, and the succession of these symptoms to one another, are also characteristic, and differ from those which attend sudden attacks caused by hemorrhage, and the slow progress of chronic cerebritis. They are all the results evidently of general pressure on the brain, and hence why mere effusion cannot be distinguished from menin- gitis. The febrile state attending meningitis cannot be depended on as a source of distinction, and the other symptoms are pretty much the same. Hitherto the treatment of meningitis, whether real or supposed, has been antiphlogistic, but it is impossible to say that any benefit has ever been effected by the practice. The early stage of the disease is generally overlooked, the vomiting and pain in the head, so long as the patient retains his consciousness, seldom leading to a suspicion of meningitis. It is only when exudation or effusion has been poured out in such quan- 372 DISEASES OF THE NERVOUS SYSTEM. tity as to cause drowsiness and stupor that our suspicions are awakened and thus it is very difficult to understand how bleeding or purging could facilitate its absorption. Besides, we have seen that the tendency of such exudation is to pass into pus; hence the treatment which favors the transformation of cell growth, as previously explained (Section III. p. 275, et seq.), must be the most effectual. For this purpose time is required, and the vital strength, instead of being lowered, should be sup- ported. It becomes, however, in actual practice very difficult to carry out these indications. The drowsiness and coma greatly interfere with the means we possess of nourishing the patient, because aliment cannot be introduced in sufficient quantity, whilst the depression of the nervous force so disorders the whole glandular system as to occasion a profound alteration of the nutritive functions. Under such circumstances the mucous membranes become deranged, the tongue and throat parched, the stomach contracted, the bowels constipated, and it often has appeared to me that under such circumstances patients literally die of exhaustion from want of food. The tissues become deteriorated, while the absence of volition and sensation, as in cases of fever, favors the sloughing pro- cess over the dependent parts of the body, which are continuously pressed upon. All these changes are remarkably well seen in those cases of the disease which occur without any complication, and when the tissue of the brain itself is free from organic lesion. In such instances a man is de- prived of his intellectual faculties merely; he is reduced to the condition of an animal which has lost its cerebral lobes ; but the man cannot be kept alive in consequence of the pressure on the encephalon deranging the nutritive functions, whereas a bird, after the experiment, may be fed and retain its vitality for months. Still the duty of the medical prac- titioner is to support the economy as much as possible—to give nutrients with moderate stimulants—to foresee the possibility of sloughs forming on the back and nates, and do all in his power to prevent them—to un- load the bowels and bladder from time to time artificially, and thus, as far as possible, counteract their torpid action—and in this way endeavor to gain time, which will enable the exudation to pass through its natural transformations, and ultimately to be absorbed. It has always appeared to me that the collection of mere serous fluid, whether in the ventricles or over the surface of the brain, either with or without exudation, is consecutive on obstruction of the vessels, and is therefore more allied to the dropsies than to the inflammations. Thus, when lymph is poured into the subarachnoid tissue at the base, it compresses the vessels leading to the choroid plexuses and lining membrane of the ventricles, and so induces effusion ; and consequently effusion follows, and does not precede the exudation. It is the collec- tion of serum which does the mischief, presses on the brain, and causes the somnolence and coma. If so, the occurrence of these symptoms should be regarded as secondary instead of as primary, and as analo- gous to the ascites or anasarca following hepatic or renal disease.* * This view was singularly confirmed by a case which entered my clinical ward during the summer of 1857. It was that of George M'Leod, ast. 25, a policeman, of sound constitution. A month before admission he experienced headache, which grad- ually increased in intensity. Nine days before admission vomiting came on, which was CEREBRAL MENINGITIS. 373 I have occasionally seen in the ventricles of the brain what may be called a desquamative meningitis, occasioned by the same minute changes which cause the corresponding disorder in the kidneys. These pathological considerations are, it appears to me, wholly opposed to the idea of blood-letting and antiphlogistics being beneficial after exudation and effusion has occurred. Case VII*—Chronic Meningitis—Serous effusion into the Ventricles— Tubercular mass in left lobe of the Cerebellum—Cretaceous tubercle in the lungs, with fibrous cicatrix. History.—James Scott, at. 30, a writer's clerk—admitted October 29, 1849. The only account that can be obtained of him is that he was seized with vomiting about a week ago, and has been ill ever since. Symptoms on Admission.—On admission he seems to be laboring under mental oppression. There is a considerable deafness and confusion of ideas, so that he can- not answer questions. He does not complain of, nor does he appear to suffer pain. The eyes are somewhat suffused. Tongue covered with a moist fur. Skin hot and dry. Pulse 70, full. Drinks freely when water is given him. No paralysis can be detected. Other functions normal. Head to be shaved, and cold applied. A saline mixture. Progress of the Case.— October 30.—In the same state, the bowels have been freely moved. Some headache, with wandering of ideas. §viij of blood to be re- moved by cupping from the neck. October 31.—No relief from loss of blood. Stupor more pronounced, with slight twitchings in the face and hands. At the visit, coma is complete. To have a turpentine injection, but he expired about 1 p.m. Sectio Cadaveris.— Twenty-four hours after death. Body robust and well formed. Head.—On removing the calvarium the cerebral meninges were unusually dry, and the convolutions somewhat flattened. The lateral ventricles were much dis- tended, and contained 5 ij of clear fluid. Cerebral substance firm and normal. The left lobe of the cerebellum was firmly adherent to the dura mater covering it. On being cut through, there was found a hardened mass embedded in it, the size of a pigeon's egg, resting inferiorly on a thin stratum of the softened cerebellar structure, about one-eighth of an inch in thickness, and of a reddish hue. It was of yellowish color and cheesy consistence, most dense in the centre. Other portions of the brain healthy. * Chest.—The pleurae at the apices of both lungs were coherent by chronic bands of lymph. Immediately below the adhesions on both sides were several cretaceous frequently repeated after taking food. On admission he was drowsy, and rapidly became comatose, the pulse 60, respirations slow. During the subsequent nine days he was two or three times less soporous, and on one occasion even answered questions confusedly. Latterly the pulse became rapid, and he died without convulsion or paralysis. A post-mortem examination showed the presence of a firm, chronic exu- dation, upwards of one-eighth of an inch thick at the base, surrounding the basilar and- carotid arteries and infiltrated through the subarachnoid cavity, so as to sur- round the pons varolii. The ventricles contained § ij of clear serum. The indura- tion, on microscopic examination, was shown to be chronic, and with its contained vessels commencing to undergo the fatty degeneration. The serum contained nothing but a few epithelial cells. In this case cupping, leeches, ice applied to the shaven scalp, and counter-irritants, were of no benefit whatever, and the only thing that appeared to do good was unloading the bowels by means of enemata; latterly, brandy and beef-tea were administered. I am of opinion that the exudation at the base was poured out long before he entered the house, but that the subsequent effusion into the ventricles, producing pressure on the brain, and causing the coma, came on after his, admission. * Reported by Mr. Alexander Christison, Clinical Clerk. 374 DISEASES of the nervous system. encysted masses, about the size of peas, surrounded by dark, indurated pulmonary tissue. On the external surface of the apex of the left lung was a dense fibrous cicatrix, three-fourths of an inch long. The bronchial glands were enlarged, and infiltrated with chronic tubercle mostly cretaceous. Other thoracic organs healthy. Abdomen.—Abdominal organs, with the exception of the scrotum, which con- tained some chronic fistula?, healthy. Microscopic Examination.—The centre and circumference of the tubercular mass closely resembled the figures represented (Figs. 402, 403); but the external softened cerebral substance contained a larger number of granular cells. The serous fluid in the ventricles only contained a few epithelial cells. Commentary.—In this case, the meninges covering the left cerebellum were thickened and adherent to the dura mater; and below them was found a tubercular mass the size of a pigeon's egg. How long this lesion had existed it is impossible to say, but its presence, by compress- ing the vessels at the base of the cranium, was well calculated to render any temporary congestion more liable to terminate in effusion. This, whatever the exciting cause, was what I presume must have occurred, producing dropsy of the ventricles, with the usual symptoms of pressure on the brain, and proving fatal. The case corroborates also the view that such effusions are rather the result of pre-existing lesions, than a direct consequence of inflammation. Case VIII.*—Chronic Cerebral Meninyitis—Induration surrounded by softeniny of a portion of the Left Cerebral Hemisphere. History.—Mrs. Swan, set. 35, wife of a coach-builder, admitted December 8,1850. She had always enjoyed good health up to four years ago, when, having contracted syphilis, and having taken a large quantity of mercury, she began to complain of headache, indigestion,' occasional vomiting, constipation, and drowsiness. About six months ago, she had a fit, from which she recovered in the course of half an hour. She suffered from similar attacks afterwards, at intervals of from two to three weeks. These attacks were ushered in by severe headache, tinnitus aurium, vertigo, and dim- ness of vision, and they were followed by great muscular debility. During the paroxysms, which lasted for various lengths of time, she was insensible; there were frothing at the mouth and twitchings of the muscles of the limbs, especially of the right arm. The last occurred two months since. Four weeks ago, she experi- enced, without any accompanying fit or insensibility, a twitching of the muscles of the right arm, together with a feeling of numbness in the fingers of the right hand. She subsequently experienced less power in the right arm, and some numbness in the right leg. Symptoms on Admission.—On admission, she appears debilitated and consider- ably emaciated. There is great mental confusion, and she often wanders. She com- plains of intense pain in the head. There is, however, no flushing of the face nor congestion of the eyes, and no delirium. There is difficulty and slowness of articula- tion. The right side of the face is slightly paralysed. The tongue, when protruded, is slightly turned to the right side. There is no diminution of sensibility. The power of motion in the right arm is diminished ; she cannot close the hand", or hold anything firmly. Sensibility is unimpaired. The right leg is not affected with any diminution of muscular power, though there is a feeling of dragging when the limb is moved. The pulse is regular and of good strength ; no cough; complains of loss of appetite; tongue moist, white; no vomiting nor sickness. Bowels consti- pated ; menstruation is irregular, and the discharge scanty; menstruated last, six weeks ago. Urine muddy, of 1023 sp. gr. : becomes clear on heating. Progress op the Case.—From this period until the 4th of January 1851, she remained pretty much in the same condition, on some days the confusion of intellect and difficulty of speech being somewhat less than on "others. The treatment con- sisted of the occasional application of leeches, and latterly of a blister to the nape of the neck, and purgatives. On the day mentioned, however, she was found comatose— * Reported by Mr. Henry Thorn, Clinical Clerk. CEREBRAL MENINGITIS. 375 did not answer questions, though she seemed to know that she was addressed—pupils moderately dilated—respiration stertorous. There was slight twitching of the muscles of the right side of the face. The right arm was rigidly flexed, and offered great resistance when an effort was made to extend it. January 5.—To-day appears better. No stupor. Expression not so drowsy. No stertorous breathing. Has spoken a little. Has no sickness or vomiting. There are still occasional twitchings of the muscles of the right side of face. Right arm not so rigidly flexed. Ordered a purgative enema immediately. January 6.—Has again relapsed into a state of coma. Breathing easy. Twitching of the muscles of the right side of the face, of the right arm, and occasionally of the right leg, have again presented themselves. Pulse rather full, and slow. Bowels freely opened by the enema. Sensibility in affected parts still unimpaired. January 7.—Continues in much the same condition. Does not seem conscious when spoken to. Sensibility still unimpaired. Pulse frequent, and smaller than yesterday. Increased rigidity of the right arm and leg, with occa- sional twitchings. January 8.—Pulse frequent, and very small. Breathing not stertorous. Lies on the left side; and the muscles of the neck are so rigid that the head is quite immovable. Apparently sensible, though she can neither hear, speak, nor protrude the tongue. Twitchings still occasionally occur in the right side of face, right arm, and right leg. Right arm rigidly contracted. Died early on the morning of the 9th. ■ Sectio Cadaveris.—Thirty hours after death. Rigor mortis well marked. Head.—There were strong adhesions between the calvarium and dura mater over the vertex, at which place the latter membrane was considerably thickened. The arachnoid membrane covering the posterior half of the left cerebral hemisphere was thickened, dense, and opaque, closely adhering to the pia mater below. The thicken- ing and adhesion existed to its greatest extent over a space about the size of half-a- crown, situated about two inches external to the falx, and at the anterior portion of the middle third of the hemisphere. Here the arachnoid membrane, united with the pia mater, was one-eighth of an inch thick; and the dense layer being carefully dis- sected off, exposed a discolored spot in the cerebral convolutions measuring an inch and a half from before backwards, and one inch transversely. The centre of this spot was indurated to the feel, whilst its circumference was soft and pulpy. In the centre there was observed a hard deposit, the size of a pea, of a bright yellow color, sur- rounded by a purple areola, passing into a pink color, and disappearing gradually towardt the margin of the spot alluded to. On making sections through this diseased portion, the discoloration was found to extend inwards and occupy a space about the size of a walnut. It contained embedded in its substance five other indurated masses, varying in size from a millet-seed to that of a pea, and similar to the one formerly noticed. The boundaries of this diseased mass internally presented the same color and consistence as were noticed on the surface, with the exception, perhaps, that the disappearance of color was more gradual internally, and passed into a pulpy white softening of the cerebral hemisphere, which extended from it in a straight line, until it terminated in the external portion of the left optic thalamus. The two lateral ventricles contained each about half a drachm of slightly sanguinolent fluid; and, in the left one, a vesicle the size of a pea, containing amber-colored matter, sprang from the choroid plexus. Other portions of the encephalon were healthy. Chest.—Heart healthy. Valves normal. No adhesion of the pleura?. The bronchi, when cut, poured out a sero-sanguinolent fluid. Left lung throughout sponcv and crepitant, with much pigmentary matter scattered through it. Right lung was non-crepitant and engorged posteriorly and inferiorly, presenting a mottled appearance when cut, from a number of minute granulations scattered throughout. All the other viscera were quite healthy. Microscopic Examination.—The yellow indurated masses described as scattered throughout the diseased portion of the left cerebral hemisphere consisted of a dense aggregation of molecules and granules, without tubercle, pus, or any kind of corpuscle. The cerebral structure surrounding these masses was loaded with innumerable granule cells and masses, which existed throughout the whole discolored portion of the brain, but became less and less numerous in the internal white softening as it approached the left optic thalamus. Indeed the most internal portion of the white softening near the optic thalamus contained none of them. 376 DISEASES OP THE NERVOUS SYSTEM. Commentary.—This woman, when she first came under my notice, presented, in a very characteristic form, the general aspect and symp- toms of softening of the brain. The dulness and confusion of intellect, without loss of volition and sensation—the weakness of the right side of the body, and contraction of the right arm—latterly the rigidity of this extremity and the coma, could leave little doubt as to the nature of the lesion, and its seat in the left hemisphere. From the account received of her history, which, however, was not entirely to be de- pended on, it appeared that for four years previously she had been subject to head symptoms and " fits" of an epileptic character, at all events involving temporary loss of the mental functions, and convulsive movements of the limbs, especially on the right side. This account was confirmed by the post-mortem examination, which exhibited chronic thickening, and adhesion to the brain, of the meninges on the left side, in addition to an inflammatory circumscribed softening, commencing in the circumference of the same hemisphere, and extending inwards to the optic thalamus of the same side. The yellow masses described were evi- dently a chronic form of exudation, and it is very difficult to determine whether they originated or followed the meningitis. Certainly they occasioned the surrounding discoloration and exudation, whieh had ex- tended inwards to the central portions of the encephalon. As regards the connection of the symptoms with the post-mortem appearances, we can have little difficulty in ascribing the commencing symptoms and "fits" to the meningitis, which increasing in intensity, caused pressure on the cranial portion of the cord, and occasioned the convulsions. The same lesion, conjoined with the external soften- ing and corresponding change of circulation within the cranium, was the cause of the confusion of intellect and stupidity latterly observed, whilst the continued irritation originating in the local cerebral inflam- mation, operating through the anterior portion of the optic thalamus, and perhaps a portion of the corpus striatum, caused the contraction and rigidity observable in the right arm. It is of course impossible to determine the amount of pressure and its direction, which any lesion may occasion, except from its effect. But it seems to me that this case is an illustration of the correctness of the pathological laws formerly given. The first symptoms are those of excitation, and are paroxysmal; these pass into more permanent symptoms; and as the organic disease proceeds from the circumference to the centre, we observe the intelligence affected most, motion secondarily, and sensation not at all. CERE BR IT IS. Case IX.*—Acute Cerebritis—Abscesses in the Brain—Old Tubercle in various Organs—Chronic Peritonitis. History.—Mary Melville, tet. 22—admitted July 20, 1851. A girl of abandoned character, concerning whom no further information could be obtained, than that she had been drinking to excess, and had sunk into a state of stupor, iiom which she could not be recovered. Symptoms on Admission.—On admission she was insensible, but three hours alter being placed in bed, so far recovered consciousness as apparently to understand ques- tions put to her, although she could not articulate. She cannot move the right arm, * Reported by Mr. D. 0. Hoile, Clinical Clerk. CEREBRITIS. 377 although the other limbs are moved freely. The eyes are suffused; pupils and eye- brows contracted; general appearance that of prostration. Pulse 120, weak; left nand occasionally applied to the head, as if pain was felt there; skin cool; breath smells strongly of whisky; breathing a little accelerated, but no abnormal rales. Head to be shaved, and ice-cold applications to be constantly made. To have 5 ss of castor-oil in peppermint water. Progress of the Case.—July 21st.—Was delirious during the night and became violent ravin^ incessantly, and trying to get out of bed, so that it was necessary to put on the strait-waistcoat. Bowels have not been relieved. Pulse 130, weak. To be cupped at the back of the neck to § viij. To have a turpentine injection. July 22d. __Still delirious. During the night vomited several times. Will take no nourish- ment. The right arm is occasionally convulsed. Bowels have been freely opened. In other respects the same. A blister to be applied to the sinciput. Nourishment to be given in small quantities, frequently repeated with § iv of wine. July 23d.—Delirium not so violent during the night, consisting of low muttering. At present seems ex- hausted. Pulse 126, small and weak. Vomiting occurs now and then, but not so frequently. Blister has not risen. To continue nourishment with § yj wine. July 21th.—Since last report the violent symptoms and vomiting have ceased, and she appears to suffer no pain, although the intellect remains confused. She was observed to move the right arm, as well as the other limbs occasionally, and took the beef tea, and other nutrients, with wine. On the night of the 26th coma came on, and on the following day she was evidently sinking. Died early on the morning of the 28th. Sectio Cadaveris.—Thirty-four hours after death. Body well formed, not emaciated. Head.—On removing the skull cap and dura mater, the arachnoid and pia mater covering the hemispheres are seen to be unusually congested. About the middle of the right hemisphere was a patch the size of a sixpence, of a dirty yellow color, which, on being cut into, was found to be the vault of an abscess, as large as a wal- nut, lined by a soft and vascular membrane, and containing one half ounce of dirty greenish pus. A similar abscess of nearly the same size was situated a little ante- riorly, and somewhat deeper, in the anterior lobe. A third abscess, the size of a hen's egg, existed in the centre of the left hemisphere, above the corpus callosum, and about one quarter of an inch from the surface of the hemisphere. The walls of these abscesses were somewhat indurated, punctated with red spots, and lined with a fibrinous matter about a quarter of an inch thick, which apparently had not yet undergone the purulent transformation. Other portions of the brain healthy. Thorax.—In the bronchial glands, and at the apices of both lungs, were several cretaceous and calcareous tubercles, surrounded by indurated black pulmonary tissue. Other thoracic organs healthy. Abdomen.—The peritoneum covering the intestines presented here and there patches of highly vascular lymph, studded with opaque granular lymph about the size of millet seeds. The mesenteric glands were enlarged and infiltrated with old cheesy tubercles. The liver and spleen contained a few granular yellow deposits. The uterus was retroverted, the os, cedematous, and the cavity of fundus filled with a glairy opaque yellow mucus. Fallopian tubes obstructed by an atheromatous sub- stance, resembling broken down and viscid pus. Left ovary somewhat enlarged, and with its fellow covered with Graafian vesicles in different stages of development. Other abdominal organs healthy. Microscopic Examination.—The pus corpuscles in the cerebral abscesses moro delicate and clear than usual, displaying their nuclei without re-agents. They were also mingled with, and surrounded by celloid albuminous deposits. The friable matter inside the lining membrane was composed of minute molecular filaments, and numerous molecules and granules. The membrane itself also had a fibrous basis, in- volving some nerve tubes, but no appearance of fibre-cells or nuclei. External to the membrane, the cerebral substance, to the depth of about a line, was composed of dis- integrated nerve-tubes and granule cells in great abundance. Case X.—Acute Cerebritis—Abscesses in the Brain—Pidmonary Tubercle —Abscess in Kidney. History.—John Dods, set. 19, a butcher—entered the Clinical ward November 9, 1855. Has been in weak health for the last two years. A week ago he was seized * Reported by Mr. R. P. Ritchie, Clinical Clerk. 378 diseases of the nervous system. with pain in the upper part of the head, not preceded by shivering, or occasioned by any obvious cause. Denies that he had been drinking. Since then he has felt hot and feverish, and says he has vomited frequently, generally about half an hour after eating. The pain has continued, accompanied with ringing in the ears, up to the present time. Symptoms on Admission.—On admission, he complains of racking pains in the upper part of the head. There is constant ringing in the ears ; the eyes are suffused • face flushed; speech confused, with difficulty in collecting his ideas. Appetite he declares to be good; no great thirst; tongue covered with a dirty yellow fur white at the edges; no pains in stomach; bowels regular; complains of cough, with slio-ht mucous expectoration. Percussion everywhere normal. On auscultation, fhere°is harsh murmur with inspiration and prolonged, expiration at right pulmonary apex • nowhere increase of vocal resonance; pulse 64, feeble; skin moderately warm ; body emaciated. Other functions normal. The head to be shaved and cold evaporating lotions to be constantly employed. Progress op the Case.—November 11th.—Passed a restless night, but says the ce- phalalgia is diminished. Pulse still weak; has taken no nourishment. To have beef tea, and | iij of wine. November 12th.—Last evening became very restless, and frequently cried out. This morning at two a. m. he screamed out violently, complained of pain in his head, and became incoherent, but when loudly spoken to, gave rational answers. Both pupils were of moderate size, the right slightly dilated more than the left, but con- tracting equally on exposure to light. At four a. m. he was seized with a general con- vulsion, preceded by a scream, in which it was observed that the left superior extremity was more rigidly contracted than the right. The right pupil now was more dilated than the left, and both contracted only feebly on exposure to candle light. The convulsion lasted five minutes, and terminated in complete coma, which continued up to the hour of visit. He was then found to be perfectly unconscious, and could not be roused. There were occasional startings of the limbs. The left foot and leg are insensible to the action of irritants, which on the right side, however, occasion slight movements.. Respiration stertorous; right pupil more dilated than the left; pulse 120, full. To be cupped at the nape of the neck, and § viij of blood extracted. Continue the applica- tion of cold to the head. At eight p. m., having been cupped, the breathing became easier; but the coma continued, and he died at three a. m. on the 13th. Sectio Cadaveris.—Eighty-one hours after death. Body emaciated. Head.—On removing the calvarium, two bulging abscesses were seen, one occupy- ing the anterior and middle third of the right, and the other the posterior third of the left cerebral hemisphere, immediately below the dura mater, which was of a greenish hue. On removing this membrane, the abscess on the right side was exposed, which was of roundish form, measuring three inches in diameter. On the left side the abscess was not quite so large, measuring two and a half inches in diameter. On cutting through these abscesses, they were seen to be embedded in the cerebral lobes, above the corpus callosum. They consisted of several excavations, varying in size from a pea to that of a hazel nut, all communicating with one another, and filled with greenish pus. Their margins presented a smooth, abrupt border, which was consid- erably indurated to the depth of one-eighth of an inch, with points of blood here and there scattered through it. The ventricles and all other parts of the brain were healthy. TnoRAx.—In the apex of right lung were about half a dozen miliary tubercles, and the pleurae over these were firmly united by dense chronic adhesions. The ante- rior surface of the left lung slightly emphysematous. Abdomen.—Abdominal organs healthy, with the exception of an abscess the size of a hazel nut, in the cortical substance of the left kidney. Microscopic Examination.—The pus in the cerebral abscesses contained pus cells, with delicate walls, floating in a liquor puris crowded with molecules. The indurated margin of the abscesses was composed of a dense aggregation of minute molecules of a light brownish color, gradually diminishing towards the healthy portion of the cerebral texture, where they were seen to be infiltrated among the tubes. Commentary.—In these two cases, abscesses were found in both hemispheres, and it will be observed that the symptoms were of the same general character as those of meningitis formerly given. The only differences observable are the more deeided convulsions and paralysis, CEREBRITIS. 379 and the less degree of delirium, somnolence, and stupor. Indeed, it may be said to be impossible to distinguish, with any thing like certainty, in individual cases, acute exudations poured into the substance of the brain, from those affecting the meninges or ventricles. The reason will be obvious when we reflect that the phenomena, in every instance, are in fact attributable to pressure on the encephalon, and that, if this be rapid and general, it can matter little whether it originate from the meninges or the centre of the cerebral lobe. In the latter case, however, as the disease progresses, there is more liability for the cranial ganglia, con- nected with motion, to become affected, and hence probably the greater amount of convulsion and paralysis. Lebert,* in an elaborate Memoir on Cerebral Abscesses, in which he has carefully analysed the histories of 80 cases, has come to the con- clusion, that what debilitates the individual, causes a predisposition to this affection. Such is also my own opinion, as most of the cases I have seen have been in scrofulous subjects, and more especially such as have labored under some form of otitis, connected with caries of the temporal bone. In the two cases recorded, effete tubercle was found in the lungs, and the general health was much deteriorated. Very little benefit can therefore be expected from depleting remedies. Hitherto, indeed, almost all these cases have been vaguely ascribed to meningitis or apoplexy. But as regards diagnosis, we are exactly in the same condition now in reference to meningitis and cerebritis, as medical men were in during the days of Cullen, as to pleuritis and pneumonitis; that is, we cannot sepa- rate them by the aid of their symptoms. Hence the following summary from Lebert's memoir, as it comprises all that is known with regard to the symptoms in 80 cases, is deserving attention:—" Sudden headache is the symptom which most frequently first excites attention; it is generally accompanied by febrile symptoms, vomiting, difficult articulation, and convulsive attacks may supervene; the patients become heavy and morose, and show delirium, contraction of pupils, photophobia; numbness and formication may supervene, and apoplectic symptoms may occur; but all these symptoms vary much in different cases. The intellect suffers com- paratively little; sensibility suffers more frequently; the headache is more or les3 intense, generally diffuse at first, and subsequently unilateral. Coma occurs frequently, but often only temporarily. Paralytic states were observed in almost one half of the cases; they were generally local, but showed themselves also in the form of general muscular debility. Diminished articulating power was observed in 10 cases. In regard to the special senses, only the affection of the ears presents any points of importance. No special symptoms are observed in reference to the vas- cular or respiratory system. Disturbance of the digestive organs showed itself in the form of vomiting in 20 cases ; involuntary defascation occurred towards the fatal termination of 11 cases. The duration of the disease appears to fluctuate from two or three weeks to two months; there is necessarily a difficulty in determining the point, as the commencement can only be approximately fixed. It occurs at all ages; but the great- est frequency prevails between the sixteenth and thirtieth years."! * Virchow's Archiv. fiir Patholog. Anat. Band x. t British and Foreign Med.-Chir. Review. April 1857. 380 DISEASES OE THE NERVOUS SYSTEM. Case XL*—Chronic Cerebritis; Epileptiform Convulsions; Hemi- plegia of the Right Side ; Loss of Smell; Blindness of the Left Eye ; Amyloid Bodies in the Brain. History.—John Bookless, set. 48, a plasterer, admitted January 7, 1855. He had enjoyed good health until two years ago, when he first complained of giddiness and gradual impairment of sight, and of smell. Twelve months ago he was attacked with " fits," three or four appearing in the course of the first night. They have occurred occasionally, at considerable but irregular intervals, ever since. His general health had remained good, until the 3d instant, when, about 12 o'clock at night, a violent "fit" appeared, which was repeated from eighteen to twenty times before six o'clock on the following morning. On the 4th and 5th he was comparatively free from them; but, on the 6th, during the night, they recurred more frequently. On the morning of the 7th, it was observed that the right arm and leg were paralysed, and he was sent into the Infirmary. Symptoms on Admission.—On admission, it was observed that the body was toler- ably robust; that he was hemiplegic on the right side; that the head was obstinately kept turned towards the right side; that speech was slow and thick; and that although conscious, he was sometime in framing an answer to a question. To have^j of castor oil. Careful investigation on the following day elicited the following facts, viz., com- plete blindness of the left eye—sight in the right eye perfect—smell absent—cepha- lalgia—frequently applies his left hand to the left side of the head—other special senses normal—loss of voluntary motion over right side, with considerable impair- ment, but not absence of sensibility—left side normal—pulse 96, full—other functions healthy. Bowels have been freely open, from the action of the castor oil. Whilst I was examining the patient, he passed through two attacks of an epileptic character— there was no scream, only a slight groan—the muscles of all the limbs became rigid —the toes and fingers incurvated—the face flushed, and the head tetanically twisted towards the right side—the mouth was drawn somewhat to the left—the left arm and leg convulsed, the right arm and leg rigid and trembling—there was complete loss of consciousness. This state continued about one minute, when the face became pale, there was foaming at the mouth, the rigidity and convulsions subsided, and in another minute he was again conscious and fully restored to his former condition. To be cupped in the neck to the extent of 8 oz.—ice to be applied to the head. Progress op the Case.—From this period he lay, in the intervals of the attacks, tolerably tranquil; the evacuations were passed involuntarily ; took nourishment with- out difficulty. The whole of the 12th he was free from convulsive attacks, but on the 13th they returned; pulse 106, soft. A blister to the neck, and §iv of wine. On the 14th the epileptic attacks returned every ten minutes, until one o'clock in the morning of the 15th. From this time he remained free from them. At the visit he was still conscious, slowly answered questions, put out his tongue, etc. The respira- tions, however, were slightly labored, and gradually became more so, until he sank, at 9 p.m., on the 16th. Sectio Cadaveris.—Fifteen hours after death. Head.—On removing the calvarium, the subarachnoid cellular tissue was infil- trated with serum, which elevated the arachnoid in some places above the level of the convolutions. On slicing the brain from above downwards, its substance was healthy. Both lateral ventricles were distended with clear serum, which, on being carefully removed with a pipette, measured 1 oz. and 7 drachms. The ventricles were some- what eslarged, but their lining walls healthy. The foramen of Monro was the size of a fourpenny piece, its edges very thin. White substance of the fornix and central portion of the brain healthy. The left corpus striatum atrophied and shrunk through- out, externally of a dull mahogany color, and, on section, composed of a diffluent fawn-colored substance, which flowed out, leaving an irregular cavity the size of a hazel nut Below the left corpus striatum, the optic thalamus presented, on section, a cribriform appearance, over a space the size of a shilling, dependent on chronic enlargement and thickening of small vessels, the open mouths of which, on being cut, were retracted into its substance. In the anterior portion of the right corpus striatum there was also a diffluent softening, occupying a space about the size of a pea. On removing the cerebral lobes from the cranium, a dense chronic adhesion, which it was * Reported by Mr. W. Gilfillan, Clinical Clerk. CEEEBRITIS. 381 necessary to cut through, existed between the inferior surface of the left anterior lobe and the dura mater. It involved the optic and olfactory nerves of that side, and extended so far on the right side as to include also the right olfactory nerve. The portion of brain in immediate connection with this adhesion was unusually indurated to the feel throughout a portion of substance in the left lobe, about the size of a nut- meg ; but, in the right, confined to a thin layer of cerebral substance externally, about an eighth of an inch in thickness, and about the size of a sMlling in its area. On cutting through the indurated substance on the left side, it felt like soft bees'-wax under the knife, was of a very pale straw color, gradually disappearing, as did the induration into the healthy structure, without any obvious limit whatever. About another oz. of sanguineous serum was found collected in the depending portions of the cranial cavity after the brain was removed. The other portions of the brain were healthy. Thoracic and abdominal viscera healthy. Microscopic Examination.—The fawn-colored softenings in the corpora striata consisted of numerous molecules, granules, granular masses, and cells, mingled with vessels coated with granular exudation, and fragments of the tubes of the cerebral substance. In and around the cribriform alteration of the left optic thalamus, numerous round colorless transparent bodies were observed which refracted light strongly, and were apparently solid. They varied in size, from the l-1000th to the l-500th of an inch in diameter. Some contained an included globular body, around which faint concentric circles were dis- cernible. On the addition of diluted sulphuric acid and iodine, they did not give the reaction of starch or cellu- lose. They were unaffected by water, acetic and nitric rig. 406. acids. Here and there they seemed to split up, not unlike starch bodies. The indurated portion of brain in the interior lobes presented an obscure amorphous appearance, consisting apparently of the normal elements, infil- trated with a brownish, exceedingly fine, molecular substance. The serum of the ventricles only contained a few epithelial cells, distended with water by endosmose. Commentary.—The symptoms observed during the life of this man were all clearly explained by the morbid changes demonstrated after death. Before the post-mortem examination took place, I ventured to diagnose chronic softening of the left corpus striatum, with a tumor so situated below it as to press upon the left optic nerve, and both olfactory nerves. Such were the principal lesions discovered, as the indurated brain and dense adhesion may in one sense be looked upon as a tumor, producing the destruction of the special nerves, whilst the extensive lesion of the left corpus striatum sufficiently explained the hemiplegia on the right side of the body. Two other lesions, however, were dis- covered, viz., 1st, The limited disease in the right striated body; and 2dly, the effusion of serum into the lateral ventricles and subarachnoid cavity. To the first of these lesions may proabbly be ascribed the con- vulsions which more especially attacked the left side of the body, although alone this would be insufficient to account for its paroxysmal character— a phenomenon which, as I have elsewhere endeavored to explain, can only be referred to congestions within the cranium.* As to the effusion •f serum, I am inclined to consider it as having occurred during the last few hours of life;—1st, Because he was conscious within twelve hours of his death, and was free from delirium and stupor; 2dly, Because, after death, little imbibition of serum had taken place into the central * See Articles by the writer on Apoplexy, Epilepsy, etc., in the second volume of the Library of Medicine. ' Fig. 406. Amyloid bodies with fragments of nerve tubes, in the cribriform sub- stance of the optic thalamus. 250 diam. 382 DISEASES OE THE NERVOUS SYSTEM. white substance of the brain, and there was consequently no softening from maceration. Case XII.*—Chronic Meningo-Cerebrilis — Sudden Convulsions__ Hemiplegia of Left Side—Softening of Anterior Lobe of Right Cerebral Hemisphere—Adhesions of Arachnoid. History.—William M'Donald, set. 38, writer's clerk—admitted November 22 1852. From the account given of him by his friends, it would seem that his habits have been of rather a dissipated nature for several years back. He was never known to have delirium tremens, but about ten months ago was seized with cephalalgia, unusual movements of the shoulders, and inability to speak or write, which symp- toms, it is said, soon disappeared. For the last six months also, he has been out of employment, and not eaten more than one meal in the day. On the morning of the 19th, he was seized with a fit, which was succeeded by profound sleep for some hours. The next day he was so far recovered as to be able to walk about, and in the evening he went to the theatre with one of his friends, who, on being interrogated, says that he did not consider him at that time in his right mind. On the 21st he had another fit, and on the 22d several others, which succeeded one another at intervals of ten minutes. Symptoms on Admission.—On admission, is still laboring under convulsive paroxysms, with loss of consciousness, and foaming at the mouth. These were always present with the exception of intervals, varying in duration from ten minutes to half an hour, during which the consciousness returns, and he answers questions cor- rectly. When a paroxysm begins, he generally utters a short groan; the mouth becomes twisted, and pulled to the left side; the eyeballs incline to the left side. During the fit the pupils are slightly dilated, and insensible to light; the left aim is thrown into violent clonic convulsions ; the left foot is extended and rigid, and the right one firmly flexed. Towards the end of the paroxysm there is foaming at the mouth; respiration is somewhat restrained, not stertorous; there is no appearance of suffocation, nor any marked lividity of the countenance. As the fit passes off, the respiration gradually becomes more free and natural; during, expiration, the right cheek is puffed out like a flaccid bag. After recovering consciousness, he can move the right arm and leg voluntarily, but the extremities of the left side are quite powerless and insensible. Pulse 98, full, but not strong. Tongue is moist and clean, and the edges marked with indentations from the teeth. On being protruded, it is turned towards the left side; no distortion of the face during the intervals ; urine during the fits is passed involuntarily ; bowels open. In all other respects the bodily functions are normal. Four leeches to be applied to each temple. The head to be shaved, and cold constantly applied to the scalp. To take ten grains of Dover's powder at bed-time. Progress of the Case. November 23, 7 a.m.—During the night has had frequent convulsive paroxysms, such as have been previously described (66 were counted). The skin never is hot, but moist. Pulse 100, full and firm ; otherwise the same. To he cupped on the temples, and 12 oz. of blood abstracted. To have immediately after- wards an opiate enema. At the visit the convulsions are almost continuous, with perhaps a minute of interval, and then another minute of violent struggles and clonic spasms. Pulse 120, strong and bounding, increasing in frequency and tensity during the attack. To be bled to 15 oz. and the cold douche applied to the head. 3 p.m.— Is now unconscious during the intervals. Pulse 160, soft. The fits, which became less frequent after the bleeding, are now as numerous as at the visit. To apply Liq. Ammonias, with a view of producing vesication, to the occiput. To have a table-spoon- ful of brandy every half hour. Sinapisms to be applied to the calves of legs. 7 o'clock p.m.—Consciousness returned after the first dose of the brandy. The ammonia \im only caused redness of the integument. Pulse 120, small and weak. On ausculta- tion of chest a loud moist rale is heard over whole anterior surface of chest. Parox- ysms as frequent as before. Continue brandy at intervals of two hours, with beef-tta. November 24.—During the night the fits became less frequent, there being often intervals of a quarter of an hour. At 7 a.m. they ceased entirely, when the breath- ing became stertorous, and stupor came on, from which, however, he could be roused until half an hour preceding death, which occurred at 9 a. m. * Reported by Mr. Alex. T. M'Arthur, Clinical Clerk. CEREBRITTS. 383 Sectio Cadaver is.— Twenty-seven hours after death. Body moderately robust, face and surface somewhat livid. Head and Spine.—Dura mater rather thicker than usual, especially so over both anterior hemispheres, but in texture healthy. There was a firm adhesion between the dura mater lining the frontal bone and the arachnoid covering the anterior lobe of ri^ht hemisphere, over a space £ths of an inch in diameter. The arachnoid membrane everywhere moist. Ventricles do not contain above 3 ss of serum. Pia mater and choroid plexuses healthy. The substance of the brain everywhere normal, except at the place in the anterior right lobe, immediately below the adhesion formerly noticed. Here the cerebral substance is softened to an extent about the size of a hen's egg. The grey and white substance cannot be distinguished; and, on section, the morbid portion is of a grey or dirty white color, of pultaceous consistence, readily disappear- ing under a fine stream of water. Frontal bone healthy. The spinal cord and its membranes healthy. The other organs could not be examined. Microscopic Examination.—Numerous fatty granules, granular masses and cells, both loose and accumulated round the blood-vessels of the cerebral softening, were visible. The tubular substance also was greatly disintegrated and broken up. Commentary.—When I first saw this man he appeared to me to be in an epileptic convulsion, but the history of the case, and the short duration of the intervals of consciousness, during which he was composed and answered questions, pointed to an organic lesion of the brain. The pulse, though full, was not very strong. Hence eight leeches were applied to the temples, the head was shaved, and ice applied. This treatment in no way alleviated the symptoms. Next day the pulse was 100, full and firm. He was now cupped over the temples, and 12 oz. of blood ex- tracted from the arm, followed by an opiate enema, but without benefit. Next day the pulss was 120, strong and bounding. He was now bled to 15 oz., and the cold douche applied to the head, with the result of making him much worse, for shortly afterwards he became insensible even during the intervals. In the evening, therefore, I at once changed the treatment, and gave brandy in table-spoonful doses, with the effect of causing immediate restoration of consciousness and a marked improve- ment. Stimulants with nutrients were perseveringly continued, but in vain. Post-mortem examination demonstrated the existence of a chronic grey softening in the anterior lobe of the right cerebral hemisphere, with old dense adhesions of the membranes over it. The cephalalgia and ob- scure cerebral symptoms during a period of ten months, were evidently owing to these combined lesions advancing slowly or at intervals. The history informs us, that during the last six months he had been out of employment and insufficiently nourished, a condition highly favorable to the disintegrating process in the brain, which at length arrived at such a point as, probably combined with an unaccustomed congestion, to pro- duce violent irritation of the motor nerves, together with such disorgani- sation and pressure as to occasion hemiplegia. If this be the correct theory of the case, an antiphlogistic and lower- ing system of treatment could not be supposed very well adapted to remedy the mischief, to prolong life, or even to alleviate the symptoms. The indication generally laid down in practical works on this subject— viz., to bleed when the pulse is strong and full—was here carried out, and failed in the most signal manner. Indeed, the most approved practice was actively followed, with the result of making the patient worse in every particular. When, however, at length antiphlogistics were aban- doned and stimulants administered, then, and then only, he rallied, and 384 DISEASES OP THE NERVOUS SYSTEM. showed for a little signs of amendment. In no case I ever met with have I been so impressed with the inutility of antiphlogistics, even when the symptoms seemed, from all our past notions, loudly to demand them. Nor, after the uselessness of these had been demonstrated, and the pa- tient reduced without benefit, could the value of an opposite practice have been better exhibited. We shall afterwards point out how unrea- sonable such lowering practice is in all organic diseases of the brain.— (See Cerebral Hemorrhage.) Case XIII.*— Chronic Cerebritis of the Right Hemisphere—Cancerous Ulcer of the Oesophagus and neighboring Glands—Fatty Heart. History.—Robert Millar, a?t. 72, married—saddler—admitted October 6, 1856. Patient states that, for the last month, he has suffered from pain in the epigastrium and from vomiting, for which he was in the habit of using Gregory's powder. For a week past had vertigo, accompanied by a staggering gait. On the evening of the 5th, his feet were so cold, that he was obliged to use a hot brick in bed ; on the morning of the 6th, he found himself deprived of the use of his legs, and was accordingly brought to the hospital. According to the account of his wife, he has experienced considerable anxiety of late ; and she thinks that bis mental faculties have been slightly impaired in consequence. Symptoms on Admission.—It is with great difficulty that the patient can be made to understand a simple question; and his answers are often contradictory. He does what he is bid; speech is slow; there is slight confusion of memory, and want of con- catenation of ideas. Sensibility appears to be present in all parts of the body except in the inferior extremities, where the patient states that he feels numbness. He has no feeling of prickling or itching. Special sensation appears normal; but he does not see so well as formerly. Complains of tenderness over the spines of the sacrum, on pressure and motion. Has not the power of moving the left inferior extremity; and some difficulty in moving the right. The left arm is somewhat stiff, and he is unable to raise himself in bed. With the exception of an unusual jog with the impulse of the heart, it appears to be healthy. Pulse 50, of good strength. Tongue covered with a whitish-grey fur, but red at the edges. Protruded straight, but sometimes spasmodi- cally jerked to the sides. Passes his urine involuntarily; which is brown, opaque, with a flocculent white sediment; alkaline. Habitually constipated. Face is thin and pinched; skin dry, somewhat cool, especially at the feet. Patient states that he has observed himself becoming thinner during the last month. Other functions normal. Habeat PU. Colocynth. Co. ij pro re nata. Progress of the Case.— October 8th.—Power of flexing the left leg has returned to a certain extent, but he is still quite unable to extend it. He can flex and extend the left forearm, but has no power of raising the upper arm on the same side. Bowels quite open; is only able to swallow fluids, and even these in very small quantities; it would appear that matters ingested pass only a certain extent down the oesophagus, and then regurgitate. October 25th.—Since last report has continued much the same. Vomiting still continues to such an extent, that everything swallowed is rejected immediately. There is tenderness on pressure in the epigastrium. An inch below, and to the right side of the umbilicus, a tumor of the size of a hen's egg is now felt, which communicates to the hand an impulse synchronous with the arterial pulse; it can, by careful manipulation, be moved to the middle line, or even to the left of it. J}, Bismuth. Alb. 3j; Pulv. Opii gr. iij; Ext. GentianIAq. q.s. ft. massa inpil.\j.\\. dividenda. Two to be taken thrice a day. Habeat enema domesticum. November 18ih. —After taking the pills the vomiting was much alleviated and has now ceased. Otherwise he has been in much the same condition as at last report. The bowels have required to be moved by means of enemata and purgatives. December 2d.— This morning he expresses himself as greatly relieved, and states that his appetite is much improved. He now answers questions slowly, and is occasionally subject to optical delusions. There is scarcely any perceptible difference between the left arm and the right; the former being used almost as freely as the latter, and presenting little or no appearance of stiffness. He can also move all the joints of the left leg, but with difficulty; stating that it is stiff, and that he has not so great command over * Reported by Mr. n. N. Maclaurin, Clinical Clerk. CEREBRITIS. 385 it as over the right. Feels a sensation of prickling, which he refers to the affected limb. Is occasionally subject to mental aberration. December 4th.—Has been very violent, and quite delirious all night. This morning there appears to be still some aberration of intellect, and occasional optical delusions. He understands, however, what is said to him, and answers intelligently, though slowly. Pupils very much contracted, and when a light is brought close to the eyes, they do not contract further. December 1th.—Again vomits his food usually shortly after taking it. Emaciation great; face pinched, with anxious expression and staring eyes. Repe- tantur PU. Bismuthi cum Opio, Habeat Vini § iv indies. December 21st.—Has not vomited since taking the pills. The delirium and excitement subsided shortly after the last report. He again took food and rallied somewhat, and continued in the same state, with occasional attacks of excitement towards evening. During the last three days, however, his strength has been gradually diminishing; there has been sopor, and latterly coma, and he died this morning at 7 a.m. Sectio Cadaveris.—Fifty four hours after death. Head.—On removing the calvarium and dura mater, a considerable amount of clear serous fluid was seen to exist in the subarachnoid space, elevating the arachnoid above the level of the convolutions. On slicing the right cerebral hemisphere several small patches of softening were observed. These were met with chiefly in the white matter of the hemisphere, but one or two were seen in the grey matter of the convo- lutions. The softening was most distinct in the upper part of the hemisphere; and disappeared towards the upper wall of the lateral ventricle. The softened portions were of a pulpy consistence, and of a white color, with here and there a slight tinge of red or yellow. No such condition existed in the left cerebral hemisphere. Each lateral ventricle was dilated, and contained about an ounce of clear serous fluid. The parts within the ventricles were natural, as well as the rest of the brain and the cere- bellum. The arteries at the base of the brain were generally opaque, and in some places rigid, from the presence of atheromatous and a little calcareous matter. Chest.—On removing the heart the coronary arteries appeared unusually promi- nent, and felt hard. The muscular substance was soft and of a fawn color. The aortic valves were competent, although a little calcareous matter was deposited at the base of two of them. There were one or two minute vegetations on the free margin of the mitral valve. The whole organ weighed 11 oz. The lungs were somewhat emphysematous superiorly and anteriorly, with one or two slight puckerings at both apices. On cutting into the pulmonary tissue, a little old tubercular matter and one or two minute cretaceous concretions were found. Abdomen.—The lower part of the oesophagus felt firm and thickened externally, and on passing the forefinger into its interior, a stricture was found to exist at the cardia, through which it could with difficulty be passed. On laying open the oeso- phagus an ulcer was found occupying nearly the whole of the mucous surface imme- diately above the cardia. When spread out, this ulcer was seen to bo of an almost regularly circular form, having a diameter of about an inch and a half. The face of the ulcer was depressed; the margins prominent and hard. The base was on the whole smooth, except that from its centre projected a sort of ridge, about half an inch in length (running parallel to the length of the tube), of white glistening appear- ance, and of almost cartilaginous hardness. This ulcer was quite limited to the oeso- phagus ; and its surface was of a dirty greenish color. The external parts were firmly matted to the portion of the oesophagus corresponding to the ulceration. Two or three enlarged lymphatic glands were here met with. On section of the largest, which was about the size of a hazel-nut, it was found to be of firm consistency exter- nally ; while internally it consisted almost entirely of a glairy juice of a slightly reddish color. The mucous membrane of the stomach and intestinal canal was healthy. The other organs, with the exception of a slight degeneration of the kidneys, were healthy. Arterial System.—Many of the arteries had their coats loaded with atheroma- tous and calcareous matter. This was especially noted in the case of the cerebral and coronary arteries; and the right common iliac artery was swollen out into a saccular dilatation, more than an inch and a half long. Microscopic Examination.—The softened portion of the right cerebral hemi- sphere was composed of fragments of nerve-tubes, with innumerable granular cor- puscles, and granular masses coating the vessels. The muscular fasciculi of the heart presented various stages of fatty degeneration. The ulcers in the oesophagus 386 DISEASES OF THE NERVOUS SYSTEM. were composed externally of granular matter, in which a few cells in various stages of degeneration were observable. The nature of these was determined by those con- tained in the neighboring glands, which abounded in cancer corpuscles, in all stages of their development. The atheromatous matter in the arteries consisted of numer- ous fatty molecules and granules, associated with a few granule cells, numerous crys- tals of cholesterine, and masses of earthly salts. Commentary.—When I first saw this man he presented the usual symptoms of chronic softening of the brain, including failure of memory, confusion of ideas, and diminution of motor power on one side of the body, with rigidity. The leading symptoms, however, were constant vomiting, from an obstruction at the cardia, and consequent emaciation and weakness. At first, nourishment was carefully regulated and given in small quantities. Subsequently, pills of bismuth and opium seemed to alleviate the vomiting, which gradually ceased. He then rallied con- siderably, was enabled to take food more freely, and became much stronger. The paralysis and rigidity of the affected limbs disappeared, and he walked about the wards affirming that he was quite well. Indeed he several times desired to leave the house. His mental faculties, however, re- manied confused, and he became garrulous, and was subject to optical delusions and intellectual aberration. In this state he continued about three weeks, when he began to wander at night, and became delirious; then symptoms of effusion within the cranium manifested themselves, and the vomiting returned. Again the pills with wine caused him to rally a little, but his strength gradually diminished, and he sunk. On post-mortem examination, chronic softening of the right hemisphere was found, explaining the effects produced on the left side of the body. The old cancerous ulcer of the oesophagus was indurated, and evidently in the act of healing up by.cicatrization, a fact which will be subsequently alluded to.—(See Stricture of the (Esophagus.) The subarachnoid cavity and ventricles were distended with serum, explaining the delirium and sopor which preceded death. The effects of treatment in this case offer a marked contrast to what was observed in the last one. It was quite remarkable to observe how there followed, on cessation of vomiting and improved nutrition, so marked an abatement in all his symptoms. Even the paralysed and rigid limbs recovered their tone, and he moved about, as if well. On the return of the vomiting, the prostration and nervous symptoms came back, and he again rallied on checking the vomiting and giving wine. No better argument could be furnished that delirium, or other evidence of supposed nervous excitement, is in fact a proof of weakness, and requires for its treatment nutrients and stimulants. Case XIV.*—Paralysis of the Abducens Occidi and Auditory Nerves— Exophthalmia—Tumor at the Base of the Cranium—Partial Recovery. History.—John Wright, sst. 30, typefounder—admitted November 26, 1850. States that four years ago he had a severe attack of rheumatism, soon after which he experienced considerable pain in the right side of the head. His right eyeball then became painful, and began to protrude. Hearing also on the same side was at first dull and then abolished. Ten months after the commencement of the headache, it abated on the right side, but became violent on the left, where it has continued ever since. He was treated with mercury and iodide of potassium. Two years since, he * Reported by Mr. Cunningham, Clinical Clerk. CEREBRITIS. 387 was attacked with spasms and grinding of the jaws, and on two occasions, the con- vulsions were pretty general and attended with loss of consciousness. His vision was quite perfect, till about a fortnight ago, when he began to see double. He continued to work until the 23d inst., when, owing to the imperfection of his sight, he was obliged to desist. Symptoms on Admission.—On admission, complains of cephalalgia, most severe on the left side. There is complete deafness on the right side. The right eyeball is very prominent; can be turned inwards but not outwards. Vision is perfect in the two eyes, but from the axis of both not being alike, is double. He cannot lay hold of an object at once, and in attempting to grasp it his hand is at first directed to one side. There is no other form of paralysis, and the other functions are healthy. Progress op the Case.—Since admission, this man has presented considerable alterations in his symptoms, the headache being sometimes more severe than at others; and on such occasions, there was considerable stupor, loss of memory, and confusion of ideas. His treatment consisted of the internal use of iodide of potassium and purgatives, with counter-irritants externally. On the 9th of February, it was noticed that the right eyeball was less prominent. On the 2oth it was ascertained, on careful examination, that he was not perfectly deaf on the right side, and that the right eyeball could be everted more than formerly. On the 1st of March the pro- minence of the right eyeball was comparatively slight. He could abduct it fully, and vision was then single. The pain in the head was unabated, but more erratic. By the 15th of March, the cephalalgia had greatly abated. There was a marked im- provement in the general health. Movements of the right eyeball normal—deafness on the right side considerable. Blisters to the temples and neck, and a variety of reme- dies have been tried, to cause sleep, and diminish the pain; of which M. xij of the Tr. of Cannabis Indica, appeared to be the most beneficial. With the exception of deafness, he was dismissed May 22, quite well. Commentary.—In this case, the deep-rooted cephalalgia, the exoph- thalmia, the paralysis of the sixth and auditory nerves on the right side, clearly indicated the existence of a solid body pushing out the eye, and pressing on the affected nerves. At one period, also, irritation of the motor branch of the fifth pair was exhibited by spasms of the jaws, with other cerebral derangements. The tumor, however, latterly diminished much in size, as indicated by the following facts :—First, return of the eyeball within the orbit; secondly, recovery of the functions of the right abducens occuli; and lastly, improvement of hearing, with diminution, and then absence of the cephalalgia. The nature of the growth in this case cannot be stated with certainty, but as it was not likely to be a cancerous, and there was no evidence of its being a tubercular formation, so it was more probably a simple exudation. Acute cerebritis is distinguished pathologically by the exudation of liquor sanguinis into the substance of the brain, whieh, if it be poured out in quautity, is transformed into pus ; if slowly or to a limited extent, it usually passes into granules and granular cells, and becomes chronic. In the latter case it constitutes one of the forms of softening previously described as exudative softening (p. 354). I have already alluded to the opinion of those who consider this to be a form of fatty degeneration, and have shown how this doctrine fails to explain the occurrence of new cell-formation in the white substance of the brain (p. 257). Besides, positive research" has convinced me, that however fatty a true inflam- matory softening may ultimately become, this is only the result of a transformation of the exuded blood-plasma. Fig. 150 (p. 168) repre- sents this plasma on the exterior of a blood-vessel from the spinal cord, in which a formative process is going on, and I have seen other cases causing rapid death, where, on examination of the brain afterwards, the 388 DISEASES OF THE NERVOUS SYSTEM. if: /ftft\ ,th.—Since yesterday has been gradually sinking; the cheeks are distinctly paralysed, and distended at each expiration. This morning the left pupil became much more contracted than the right; the cornea) became dim, and the respirations 40 in the minute; the pulse fluttering; coma supervened ; and he died at 2 p. m. on the 7th. Sectio Cadaveris.—Twenty-three hours after death. Head.—Surfaces of the arachnoid moist; slight serou3 effusion between the sulci of the cerebral convolutions. On slicing the hemispheres, their substance exhibits a greater number of bloody points than usual. They are symmetrical; the right lateral ventricle somewhat smaller than the left. The two contained 3 iij of transparent serum. The right optic thalamus was decidedly larger than the left one, and at ita base, near the corpus striatum, presented on section a well-marked cribriform appear- ance. In the posterior fourth of the substance of the left corpus striatum was a dif- fluent mass the size of a pea, which flowed out on section, having a small cavity with the walls of a fawn color. Both choroid plexuses contained simple cysts, the greater number on the left side. On cutting through the pons varolii, its centre was found softened, and of a pulpy consistence, the upper half more than the lower, and the right more than the left side. The whole softened portion was gradually washed away by a thin stream of water, showing a distinct irregular margin, inclosing a cavity about the size of a hazel-nut. The basilar artery, throughout its whole course, was opaque, its coats loaded with calcareous and atheromatous matter, and obstructed by a colorless clot, which at one point was transformed into mineral matter. Spinal Cord.—The spinal cord was carefully examined, and found to be healthy. Chest.—The inferior lobe of left lung hepatized, of a dirty grey color, and in the upper lobe two masses of pneumatic condensation about the size of walnuts. Mar- gins of both lungs emphysematous. Heart healthy. All the other organs were healthy. Microscopic Examination.—The contents of the old apoplectic cyst in right corpus striatum had disappeared, but the indurated walls consisted of a dense aggregation of brownish opaque molecules, which gradually diminished in number externally, and were gradually lost among the tubular and granular substance of the striated body. The softened portion of the pons varolii was entirely composed of the disintegrated tubular and vesicular structure of this portion of the encephalon. There were no granule-cells or granular masses, such as are found in softening from an exudation. But the nerve-cells contained an unusual number of minute brownish granules, and floated about isolated in the softened substance, as seen in Fig. 405. The clot in the basilar artery contained irregular masses of phosphate of lime, which at one point were so closely aggregated together as in themselves completely to block up the vessel. The hepatization of the left lung presented all the stages of the congestive, exudative, and suppurative stages of pneumonia. These were remarkably well seen in the two masses in the upper lobe, in which the centres were soft and purulent, the air vesi- cles filled with pus, and the surrounding mass indurated, exhibiting different stages of the transformation of an amorphous exudation into cells. (See Fig. 154, p. 174, which was drawn from a demonstration made from one of these masses.) Commentary.—After vertigo and other head symptoms for many years for which he was in the habit of being bled, this man, in conse- quence of unusual bodily exertion and mental anxiety, was suddenly seized with paralysis in the left arm without loss of consciousness. This was followed by paralysis of speech, and of the other limbs, inability to 392 DISEASES OF THE NERVOUS SYSTEM. pass urine or retain the faeces, and spasmodic closure of the jaws. These symptoms indicated a lesion of the central part of the brain, which, from the suddenness of their occurrence, I supposed would be a hemor- rhage either in or pressing upon the pons varolii. But on elimination there was found an old apoplectic cyst in the left corpus striatum, which did not appear to have caused any of his recent symptoms, and is not accounted for in his history. The general paralysis was evidently owing to the softening of the pons varolii, and this in its turn was certainly not dependent on an exudation from the blood-vessels, a fact which I ascertained by careful and prolonged microscopical examination. I could not therefore resist the conclusion, that the disorganization of the nervous substance was attributable to the obstruction in the basilar artery, and a peculiar fatty degeneration commencing in the nerve-cells. Of this lesion we shall be able to form a better idea after examining the facts of the following case :— Case XVI.*—Apoplexy—Hemipleyia of left side—Convulsive attacks- Cardiac and Renal Disease— Old Clot in the right Cerebral Hemisphere, with surrounding softening. History.—Elizabeth Ross, set. 26, married, admitted May 23, 1853. States that about 4\ years ago she suffered from acute rheumatism, on recovering from which she frequently experienced palpitations, and during the last 18 months there has been occasional epistaxis, preceded by giddiness, dimness of vision, and muscae volitantes. Last January, when quietly sitting in a chair, she suddenly fell to the ground insen- sible, in which condition she remained 48 hours. On recovering her consciousness, she could not speak; the left half of the body and face was deprived of motion and sensibility. Five weeks afterwards she began to regain her speech and the command of the left arm and leg, but observed at the same time an cedematous state of the feet and legs, and that this gradually spread over the whole body. Three weeks ago she a°-ain became suddenly insensible, and continued so 1\ hours, during which time she was much convulsed. She had three similar fits during the succeeding ten days, which were preceded by a choking sensation in the throat, palpitation and uneasiness in the precordial region. Symptoms on Admission.—On admission there is still partial paralysis of the left side of the body, which is much colder than the right side. On attempting to walk she cannot raise her left foot completely from the ground, but drags it behind her. She cannot bend her left wrist or arm, or raise them so readily as she can those of the right side. Her mouth is slightly drawn to the right side, and the tongue when protruded appears to be somewhat to the left of the mesial line. The sensibility over the whole left side is somewhat impaired. She complains of uneasiness in the precordial region. Action of heart strong, but rhythm regular. Apex beats between the 5th and 6th ribs, about half an inch to the outer side of the nipple. Transverse cardiac dulness 2\ inches. A blowing murmur is heard with the first sound at the apex, and a double blowing murmur at the base, of which that with the second sound is the loudest and longest, and is distinctly audible in both infra-clavicular spaces.^ Immediately above the right stemo-clavicular articulation considerable pulsation is visible to the eye, but no tumor can be defined upon manipulation. Over this part a harsh single blowing murmur is audible, and fremitus is very perceptible to the finger. No venous pulsation. Radial pulse 87 per minute, strong and hard, communicating a jerking sensation to the finger. The voice is weak, and articulation difficult and indistinct. Respirations irregular and spasmodic, 20 per minute. No dyspnoea. Cough short: expectoration scanty. Chest resonant everywhere on percussion, and the only abnor- mal sound audible is a fine moist rattle with inspiration over the two lower thirds of left lung posteriorly. Tongue is red and dry; appetite very bad, and dysphagia to such a degree that she can only take liquid food. Slight epigastric tenderness. Bowels costive. Micturition difficult, painful, and frequent. Urine of pale color, neutral reaction, sp. gr. 1010, with deposit of triple phosphate on cooling; quantity * Reported by Mr. Joseph Johnston, Clinical Clerk. CEREBRAL DISEASE FROM OBSTRUCTION OF ARTERIES. passed small, and deposits when heated a considerable coagulum. There is general oedema of the whole surface of the body, but especially of the inferior extremities. 1} PU Scillce el Digitalis, vj: Sumat unam bis in die. R PU. Opii, gr. i. hora somni sumcnd. Habeat Elect. Laxans l'\];et repetalur post horas sex si opus sit. Progress op the Case.—May 25th.—Sleeps better. Bowels relieved, ffidema of upper part of body diminished. Urine still in small quantity, highly coagulable, and containing waxy and fatty casts. Heart's action not so strong. June 6 and on the 24th she was removed to the Symptoms on ADMissiON.-Great pain is felt over the top of the head, which is 28 * Reported by Mr. M'Arthur, Clinical Clerk. 402 DISEASES OF THE NERVOUS SYSTEM. constant, and prevents the patient from stooping. Speech thick and imperfect. The muscles of the left superior extremity are completely paralysed, and do not ad- mit of extension; the muscles of the head and face are not affected, nor is sensibility impaired. Cannot move the left leg, but on applying an irritant to the sole of the foot the limb is at once retracted. Pulse 120, of good strength; other symptoms normal. The head to be shaved, and ice to be applied to the scalp. To have a purgative bolus. Progress of the Case.—On the following day the pain in the head was much relieved, and from this time she slowly regained the use of her arm and leg. Her recovery, however, was retarded by a carbuncle which formed over the right inter- scapular region, and subsequently by an exanthematous eruption, accompanied by considerable fever. She was dismissed April 8th, when she could walk with the aid of slight assistance, and move the arm of the affected side without difficulty. Commentary.—In this case sudden hemiplegia occurred without loss of consciousness, when the individual was wide awake and performing her household duties, a fact which was established by frequent interro- gation and by the accounts of others. It may be presumed that a vessel had suddenly given way, causing hemorrhage into the right cerebral hemisphere. The clot must have been larger than in the last case, not only because the paralysis was more extensive, but from the loDger time necessary for recovery. Case XXL*—Sudden Paralysis of Face and Left Arm—Pneumonia— Bright's Disease—Recovery. History.—Christina Hutchinson, ret. 40, married, a sempstress—admitted Novem- ber 7, 1854. She states that on the 5th inst., at half-past 1 o'clock a.m., on waking from sleep, she found that she was unable to lift the left arm, and that she had lost the power of speech. She also experienced intense general headache, as well as great pain in the right side of the face, which was greatly swollen. She does not know whether she was insensible previously. On the preceding evening she had gone to bed healthy and strong, though with a sense of fulness in the head. Though habit- ually enjoying good health, she had occasionally had palpitations, with dizziness of the head, dimness of sight and tinnitus aurium, especially brought on by stooping. Seventeen months ago she had an attack of acute rheumatism. Symptoms on Admission.—Her speech is somewhat embarrassed, and her intelli- gence dull, though she is quite conscious of surrounding objects. Hearing perfect. Sees dimly. Left pupil does not contract so readily on exposure to light as the right. The face is dragged to the right side. Cannot lift up the left arm, though she can nrove it slightly by a strong effort of volition; neither can she grasp an object firmly with the left hand. Sensibility of the limb much diminished but not lost. The left leg and side unaffected. Tongue when protruded seen to be loaded and apparently turned to the left, although this is really owing to dragging of the mouth to the right side. Deglutition, especially of liquids, difficult. Bowels constipated. Slight pain in the loins. Urine slightly coagulable, sp. gr. 1014. Pulse 86, small and weak. Heart normal. Other systems healthy. A blister to be applied to the nape of the neck. To have 01. Ricini § ss. Quietude and rest enjoined. Progress of the Case.—November 14th.—Since admission, has gradually recovered her intelligence and power of speech, the features of the face are less distorted, and the sensibility in the left arm has been augmented. There has been constipation, which required pills of colocynth and croton oil to overcome. To-day complains of a sharp pain in the left lateral region of the mamma, increased on deep inspiration. The dulness on percussion but slight; sibilation audible on auscultation. November 28th.—Since last report, has had an attack of pneumonia, involving two-thirds of the left lung, and characterised by all the signs and symptoms of that disease. (See Pneumonia.) To-day she has completely recovered, the pulmonary disease has passed through its usual course, leaving her, however, weak and thin. The appetite is now good, the strength improving. The sensibility and power of motion in the left arm nearly restored. Dragging of the mouth nearly disappeared. December 11th.—Since last report all trace of the pulmonary disease has disappeared. A week ago, however, * Reported by Mr. 0. Beaugeard, Clinical Clerk. CEREBRAL HEMORRHAGE. 403 she experienced considerable pain in the lumbar region, and on examining the urine it was found that the albumen had greatly increased. To-day microscopic examina- tion demonstrates in addition numerous fatty and waxy casts of the tubes. Urine pale passed in good quantity, sp. gr. 1010. She states that the ankles swell towards evening. Habeat Potass. Bitart. 3 j ter die. January 1st.—Has been gradually gain- ing strength; all trace of the paralytic attack has now left the face and arm. Careful examination of the left lung can detect no remains of the pneumonia. The urine is still coagulable on the addition of heat, but much less so than formerly. But it con- tains nocasts of the tubes, is passed in good quantity, and the oedema of the feet has disappeared. Dismissed at her own request. Commentary.—The peculiarity in this case was the sudden occur- rence of palsy in the left arm and left side of the face during sleep. This was most probably owing to a limited hemorrhage compressing the origin of those nervous filaments more immediately in relation with the nerves supplying those parts. Such hemorrhage was not likely to have been extensive, as we may assume that recovery followed on the gradual absorption of the clot. It is worthy of observation, that this woman had formerly suffered from an attack of acute rheumatism, and was liable to palpitations of the heart. On admission, no valvular lesion could be discovered, and yet there supervened many of those phenomena supposed to result from coagula in the blood, causing first, cerebral hemorrhage, then pneumonia on the left side, then renal disorder. The occurrence and gradual recovery from each of these diseases in succession is rarely observed. Case XXII.*—Apoplexy—Extravasation of Blood into the Left Corpus Striatum—Pneumonia—Arrested Tubercle of Lung. History.—Isabella Bain, set. 59—admitted May 20th, 1855. She was brought to the Infirmary by some policemen, who had found her insensible in a common stair. Symptoms on Admission.—On admission she was completely comatose; the breathing stertorous; pupils contracted; countenance pale; pulse 120, weak and irregular. One drop of croton oil was administered immediately on a piece of sugar, and afterwards a turpentine enema. Progress of the Case.—May 21st.—Coma continues. The enema brought away some scybalous faeces, and she has since had several loose stools, which were passed in bed. There is now complete paralysis of the right side, and the mouth is strongly drawn to the left side. Head to be shaved, and cold constantly applied. May 23d. Has continued insensible. She now breathes with difficulty, and with heaving of the chest. There is marked dulness over inferior two-thirds of right lung, but no mur- murs are audible there, in consequence of the stertor. May 24th.—Slight occasional movements have been observed in left arm. In other respects the same. Paralysis of right side of face well marked. Loud moist rattles are now audible over right side of chest. Dyspnoea more urgent. Blister to the head. Died at two a.m. on the 25th. Sectio Cadaveris.—Thirty-four hours after death. Head.—The arachnoid membrane covering the convolutions considerably elevated above the sulci, in consequence of fluid in the subarachnoid cavity. The veins cover- ing the hemispheres everywhere turgid with blood. On slicing the left hemisphere from above downwards, the knife passed through a clot of blood in its centre, about the size of a walnut. The left lateral ventricle was also filled with recent coagulated blood and sanguineous fluid. On removing the brain, and cutting through the diseased parts, it was seen that the seat of extravasation was the left corpus striatum, the posterior third of which was broken up, and reduced to a pulpy consistence of a red color. It was surrounded by a zone of hemorrhagic purple spots closely aggre- gated together, extending half an inch into the surrounding white substance, and this again surrounded by another zone of a gamboge yellow color, gradually dying away * Reported by Mr. D. Macgregor, Clinical Clerk. 404 DISEASES OP THE NERVOUS SYSTEM. into the healthy white structure of the cerebrum. The choroid plexuses both contained several cysts, one or two of which were the size of large peas, and filled with an opaque yellow fluid. The vessels in the Sylvian fossae were unusually large, thick, and rigid from atheromatous deposit. The right hemisphere was normal. Some of the more fluid portion of the clot on the left side had infiltrated itself below the cerebellar arachnoid and was accumulated in a thin layer over the convex margin of the cerebellum on both sides Thorax.—A few atheromatous patches on the lining membrane of aorta and of the mitral and aortic valves. The heart was healthy. The pleurae on the right side were everywhere united by chronic adhesions. The two inferior lobes of the right June were hepatized, readily sinking in water, with a few scattered tubercles The apex was cedematous and spongy. The apex of right lung was indurated, strong puck- ered, of blackish color, and contained several cretaceous and calcareous concretions varying in size from a pin's head to that of a small walnut. The rest of the lung was spongy, but at the base were two or three masses of chronic tubercle the size of fil berts, surrounded by a dark ring of pneumonic condensation. Abdomen.—Abdominal organs healthy. Microscopic Examination-The softened portion of cerebral substance sur- rounding the clot consisted of disintegrated nerve-tubes and blood globules and con- tained no granule cells. The opaque fluid in the cysts of the choroid plexus contained numerous delicate cells, globular in form, and varying in size from the l-2000th to 1-500th of an mch in diameter. They contained a single nucleus, also varying in size, sometimes clear, at others containing numerous granules. There were also numerous irregular masses of granules and mineral bodies, which, on the addition of nitric acid, were rendered very transparent, whilst the larger ones presented a series of concentric rings surrounding a nucleus. They resembled the amyloid bodies so commonly found in the choroid plexus. (See Fig. 393.) Commentary.—This case is an example of death from primary hemorrhage into the left ventricle and corpus striatum, the result of chronic arteritis. She died five days subsequent to the attack, during which period a pneumonia had been developed in the right lung, one of the most common sequelae of severe lesion at the base of the brain. The woman was apparently in good health previous to the attack, which was induced by ascending a stair. Case XXIII.*—Apoplexy—Hemiplegia of left side—Hemorrhage into right Cerebral Hemisphere—Diseased Heart—Pneumonia. History.—Margaret Wales, ict. 55, married—admitted January 10,1849. On the 1st instant patient and her husband left their home quite well, and walked about the streets for about two hours, when, feeling cold, they entered a spirit shop and drank each a glass of whisky. On leaving the shop she suddenly fell down on the left side, insensible. Next morning she began gradually to revive, being evidently conscious, though not speaking. Her friends say that she remained quiet in bed, with the eyes mostly closed. There was no distortion of the face. The right aim and leg felt very cold, but were frequently moved. The left arm and leg of natural temperature, but completely paralysed. On the evening of the 4th she became delirions, muttering and roaring out. This continued until the 7th. During this time she was seen fre- quently to move the right arm and leg, but not the left. On the 8th was somewhat drowsy, but so far conscious as to speak when roused. On one occasion asked for a glass of whisky, but had some tea given her. In the evening of this day again be- came comatose, and has continued in this state until admission. Has had no medical attendance, and the bowels, it is said, have not been relieved since the attack. Symptoms on Admission.—On admission the face, hands, and feet are cold, and of bluish aspect, not unlike that of cholera. The trunk moderately warm; eyelids closed; pupils slightly contracted, and insensible to light. She is quite insensible, the strongest stimuli failing to rouse her. There is considerable dyspnoea (respira- tions 40 in the minute); no stertor, but some tracheal rales; pulse 100^ soft and small. Bronchial moist rales are very general en auscultation over anterior surface of chest, which is also resonant on percussion, with the exception of lower half of right chest, where there is comparative dulness. Heart's sounds are weak, and * Reported by Mr. James Struthers, Clinical Clerk. CEREBRAL HEMORRHAGE. 405 masked by bronchial rales. The right arm and leg, on being pinched, move slightly, but the left arm and leg are completely paralysed. The left side of face also com- pletely paralysed, but no distortion; slight movement of facial muscles on the right side, when they are pricked with a pointed instrument. No injury of scalp or cra- nium can be detected. R Olei crotonis gutt. ij ; Exlr. colocynth. comp. q. s. ft. pil. to be taken immediately. A large sinapism to be applied to each leg. Head to be shaved, and a blister applied to the occiput. Progress of the Case.— January 11th.—Continues in the same condition. Bowels not open. To have a pill, with ol. crotonis gut. iv. A piece of lint 3 inches square to be dipped in strong aqua ammonice, and applied to the vertex. January 12th. —No improvement, though the bowels have been opened once copiously. Breathing is more rapid, with tracheal rale. Surface cold, and covered with a clammy sweat; pulse almost imperceptible. Died in the evening. Sectio Cadaveris.— Twenty-three hours after death. Considerable livor, with oedema of hands and feet. Integuments loaded with fat. Head.—On reflecting the scalp no wound or contusion was anywhere visible. Membranes of the brain healthy. On slicing the brain from above downwards, a slight prominence was observed over the right lateral ventricle, and the cerebral substance forming its roof was softened, and of a reddish brown color. On opening the right lateral ventricle, its posterior half was seen to be occupied by a clot of blood, which also infiltrated the surrounding cerebral substance to the depth of several lines, which beyond the infiltrated portion was also softened to the extent of half an inch, the dark red gradually passing through fawn-colored into white softening. The left ventricle was slightly distended with serum. The foramen of Monro enlarged so as to admit a goose quilL Cerebral arteries studded with patches of atheroma. Thorax.—Heart slightly hypertrophied, otherwise healthy. Aorta healthy. Both lungs much congested, and the bronchi filled in many places with muco-purulent matter. The lower half of the inferior lobe on the right side hepatized. On section it presents a dusky red color, containing here and there circumscribed purulent- looking deposits about the size of a millet seed. Abdomen.—Liver slightly enlarged, its right lobe adherent to the diaphragm by chronic adhesions. Gall bladder greatly distended; colon loaded with indurated fieces. Other viscera healthy. Microscopic Examination.—The white softening of the brain surrounding the clot externally consisted of the mechanical breaking up of the nerve tubes, as figured Fig. 404. The fawn-colored and reddish portions of the softening contained nume- rous granule cells, mixed with broken-down clots of blood, some of which were of a bright orange color, mingled with numerous crystals of hematoidine. (Fig. 349.) Commentary.—This case was very like the last, viz., chronic arteritis, followed, by extensive hemorrhage into one of the ventricles, induced by walking about the streets, after the excitement of drinking whisky. Pneumonia of one lung was also induced. She rallied somewhat from the attack, but again relapsed into coma, which is a very unfavorable sign. The importance of administering a purgative was here well demonstrated, the paralysis having affected the bowels, and caused constipation for ten days, which was with the greatest difficulty even imperfectly overcome. After death the colon was found loaded with indurated faeces. Case XXIV.*—Apoplexy—Hemorrhage at the base of the brain in a boy aged 14 years. History.—-Thomas Pitbladdo, set. 14, a house-painter's apprentice—admitted on the evening of June 6, 1855. His father states that he has generally been a healthy lad, but occasionally complained of pain in his head. This morning he got up as usual and went to his work. He ate his breakfast and dinner at the usual times not so heartily, it is said, as he was accustomed to do, but he made no complaint. Between 2 and 5o clock p.m., he was in the streets carrying errands for his master, durhi" which time he purchased and ate several partially-decayed oranges. On returning to' * Reported by Dr. Wilson Fox, Resident Physician. 406 DISEASES OP THE NERVOUS SYSTEM. the workshop he was noticed by the workmen " nearly to fall" from giddiness, and to vomit several times, bringing up the oranges he had eaten. At half past 7 p.m. his father was sent for, and found him complaining of pain in the head and abdomen. Subsequently he was observed to grmd his teeth. An emetic of ipecacuanha was obtained from a neighboring druggist, which operated once, slightly. He was brought to the Infirmary at 10 p.m. Symptoms on Admission.—On admission he complained of pain in the abdomen on which he pressed his hands. Coma was apparently coming on. Pupils dilated.' No strabismus. Pulse natural. Progress of the Case.—On being conveyed to bed, an attempt was made to pass the stomachipump, under the impression that the case was one of poisoning. This however, failed in consequence of the firm spasmodic contraction of the jaws, accom- panied by grinding of the teeth. Warm fomentations also were applied to the abdomen. He now became completely comatose, and it was observed that there was strabismus inwards of the left eye with contracted pupil, the right one being fixed with dilated pupil. He lay motionless, with the exception of slight clonic spasms of the left hand and forearm. A purgative enema was given, which returned un- changed. He was then placed in a warm bath. The spasmodic contraction of the jaws, however, continued, the respirations gradually became more laborious, and he expired about one a.m. on the 7th, without having had any convulsion. Sectio Cadaveris.— Tioelve hours after death. Considerable rigor mortis. Sugillation strongly marked; jugular veins turgid with fluid blood. The blood in the heart and all the vessels fluid. Head.—No marked congestion of the scalp. On raising the dura mater, both surfaces of the arachnoid were observed to be unusually dry. Substance of hemi- sphere healthy. The lateral ventricles contained about ? ij of sanguineous serum. At the base of the brain was a clot of blood, forming a round tumor the size of a walnut, situated below the arachnoid, and breaking up the cerebral substance sur- rounding the fifth and third ventricles, and the inferior portion of the optic thalami, between the pillars of the fornix, thereby communicating inferiorly with the lateral ventricles. The sanguineous mass was about an inch in depth. Arteries everywhere healthy. Thorax and Abdomen.—Thoracic and abdominal organs healthy, with the ex- ception of an ecchymotic circular patch of a brick-red color, four inches in circum- ference, in the mucous membrane lining the great curvature of the stomach. Microscopic Examination.—The clot composed of recently coagulated blood. The surrounding softened cerebral substance exhibited the nerve-tubes broken up to a remarkable degree, and presenting numerous rounded bodies, with double outlines either isolated or attached to the tubes. The varicosities of the tubes also could readily be increased by pressure. (See Fig. 404, which was drawn from a demonstra- tion of the softening in this case.) Commentary.—Cerebral hemorrhage is a rare idiopathic lesion in very young persons, and the causes leading to its occurrence in this case are inexplicable. There was no heart disease, nor could coagula be found in any of the vessels. On receiving the patient at night, the house physician, as stated in the report, was led to suppose that the boy had eaten some poisonous substance, and the treatment was founded on this supposition. Pathologically, it is interesting to observe how the same lesion, which in an elderly person would have occasioned coma and paralysis, in the boy caused grinding of the teeth, trismus, and spasms. Coma subsequently came on, probably from the accumulation of serum in the ventricles. Case XXV.*—Apoplexy, followed by Delirium, and proving fatal in eight hours—Hemorrhage into the Meninges of the Brain. History.—Elizabeth Vicars, aet. 59, brought by the police to the waiting-room of the Infirmary, at 2.30 a.m., May 30* 1857. Three and a half hours before admis- * Reported by Dr. John Glen, Resident Physician. CEREBRAL HEMORRHAGE. 407 sion patient was seated in her own house (Canongate) by the fireside undressing She is reported up to that date quite healthy, although of intemperate habits, and given to quarrelling with her daughter. She was not subject to giddmess; never attacked by fits nor by palsy. Suddenly at 11 p.m., 29th of May, she was observed to fall off the seat, not striking her head against anything. She remained insensible for 10 minutes, and on emerging from unconsciousness, rolled on the floor and shouted —" Murder—Police—I'm mad," etc., and could not be kept quiet. Symptoms on Admission.—When seen in No. X. she was lying quiet on her left side, as laid down by the police; heart's sounds normal. Respiration not stertorous, but natural; pulse 80, of ordinary strength; legs rather cold; body warm. The pu- pils were equal, rather contracted than dilated; lips not blanched, face naturally pale; the eyelids had been closed. On their being opened, patient began to show restless- ness, "and this increased when her lower garments were being removed. She shouted and moved from side to side, putting her legs out of bed, and moving both arms freely. The mattress was laid on the floor. Warm bottles were applied to the feet, and cold to the head. Pest and perfect quietude enjoined. She was seen again about 3 a.m., by the house-physician (Dr. Glen); at that time she was lying quiet. She is reported to have had a spontaneous recurrence of the restlessness, and tendency to vociferate, again sinking into apparent repose. At 7 a.m. she was recognised by the nurse to be dead. Sectio Cadaveris.—Fifty-five hours after death. Body well formed, somewhat emaciated. Head.—On removing the dura mater, a hemorrhagic extravasation was found to have occurred below the arachnoid. It covered nearly the whole of the surface of the hemispheres, and formed a thin layer, thickest towards the lateral external surface on both sides. The extravasation was still more abundant over the base, where it was half an inch thick; it extended from a little anterior to the optic commissure to the commencement of the spinal cord; it was particularly abundant around the medulla oblongata. The blood was of a dark color and very loosely coagulated. The fourth ventricle contained a clot of similar character. There was a cavity filled with blood in the anterior portion of the right hemisphere, communicating with the ex- travasation into the meninges. It was of the size of a chestnut, but did not extend back into the lateral ventricle—the parts contained in which were quite normal. The arteries at the base of the brain were atheromatous; numerous opaque yellowish patches being found on nearly all the branches. No ruptured vessel, however, could be made out. Thorax.—Heart weighed 11£ oz.; the left ventricle being slightly enlarged, appeared paler and browner than usual, being found on microscopic examination to be in an advanced state of fatty degeneration. The valves were healthy. On the anterior flap of the mitral valve, and on the endocardium below the origin of the aorta, there occurred several opaque atheromatous patches. The surface of the aorta, chiefly in the ascending portion, but also down to the bifurcation of the ab- dominal aorta, was irregular from hypertrophy of the lining membrane, with athe- romatous and slight calcareous degenerations. Various of the branches were simi- larly affected, but to a less degree. There were a few old adhesions cf the pleura?, and slight emphysema anteriorly of both lungs. Abdomen.—Abdominal organs healthy. Microscopic Examination.—The coagula of blood presented nothing unusual, and the brain surrounding the extravasation in the anterior lobe of the right hemisphere was only mechanically broken up. The atheromatous patches in the cerebral avtcrie3 exhibited the usual structure of that bsion. Commentary.—In this, as in preceding cases, chronic arteritis had led to hemorrhage, which, however, was for the most part poured into the subarachnoid cavity. The symptoms in consequence presented a remarkable modification, for after the first apoplectic phenomena had disappeared, she exhibited no paralysis, but great restlessness, and delirium with vociferation. These are exactly the effects which result from any acute disorder of the meninges, and indicate how all lesions, by affecting the same parts of the nervous mass, produce similar symp- toms. (See p. 153.) 408 DISEASES OF THE NERVOUS SYSTEM. Case XXVI.*—Hemorrhage into the Right Cms Cerebri—Meningitis at the base of the Encephalon—Serous Effusion into the Lateral Ventricles—Chronic Phthisis—Vertigo—Paralysis—Spasms of the Jaw—Delirium and Coma. History.—George Crichton, set. 28, brewer—admitted Jan. 31,1851. For the last six months he has suffered from a short dry cough, and has sweated profusely at night- His appetite has been good, and he considered himself in good health. Three weeks ago he felt pain in his head, which gradually increased in intensity, although he con- tinued at his work. On the 26th, feeling the headache very severe, he applied eight leeches, but without relief. On the following day, as he was going to his work, he had a severe fit of coughing, and expectorated a teaspoonful of florid blood. Imme- diately after he felt giddy and stupid, being obliged to support himself against a wall. He says he never lost his recollectipn, recovered himself in a few minutes, and walked home, but with difficulty; afterwards he felt weak, but had perfect command over all his muscles. On Tuesday evening he felt drowsy, and en awakening from one of his short sleeps, he discovered that the power of moving the left arm was much diminished. The left leg was unaffected. Symptoms on Admission.—On admission, appears weak and emaciated; com- plains of pain in the forehead; most severe on the right side; has no pain else- where. His intelligence seems but little affected. He speaks slowly, reluctantly, and with an effort. The special senses are unimpaired. The power of motion b his left arm and leg is almost entirely gone. He can neither stretch or flex his arm or leg. His leg has become much more useless within the last twenty-four hours. Sensibility of the parts is unimpaired, and he feels impressions made upon them. His mouth is very slightly twisted to the right side; tongue protruded straight. During the examination before the class, he was seized with spasmodic movements of the lower jaw, lasting for a minute and a half, unattended with pain. This was first observed on Wednesday,—when it occurred nine times,—and has returned at irregular periods since. Pulse 60, not increased in strength. Cardiac sounds normal. Appetite good. Tongue clean in centre; covered with a white fur at edges. Bowels generally costive; not opened by medicine last night. Urine 1027 sp. gr.—deposits a copious sediment of mucus and phosphates. Has occasional slight cough; there is dulness on percussion under left clavicle, with harsh inspiration; and great increase of vocal resonance. He was ordered ice to the head; quietness to be maintained. Progress of the Case.—Feb. 2.—To-day headache is abated, he complains of weakness in the right eye, which he cannot keep open without an effort. On frown- ing, the corrugations are more distinct over the left eye. The right pupil is less con- tracted than the left. Feb. 3.—Slept ill last night, had a good deal of convulsive twitching of the unaffected side. Is more confused. Tongue has a dense white fur over it. Bowels costive. R Olei Ricini § iss, to be followed by laxative enema, if required. Feb. 4.—Bowels moved after administration of the injection. Eas had a good deal of muttering delirium,—passes his urine in bed. Appears to know he is addressed, if spoken to in a loud voice, but gives no answer. Pulse 60. t'mall and weak. Twitchings more distinct and decided. Breathing not labored. R Larb. Amnion, gr. xij; Mist. Camph. 3 vj; M. Signa, two table spoonfuls every third hour: Applicetur Vesicat. (3 x 4) ad Nucham.—Cold to head. Feb. 5.—Muttering delirium last night; does not seem to feel a prick on his left leg; is restless when spoken to, but never speaks. Pulse 60, still small, but stronger than yesterday; has some dysphagia. Feb. 6.—Quiet during the night; had a slight attack cf general convulsions; bowels opened by enema. Pulse 75, of good strength. Fib. 7.—Was more restless during the night; picking the bedclothes; no muttering; respiration is more hurried and labored; there is puffing of the left cheek during expiration; left pupil more contracted than right; jactitation of the right arm. Feb. 8.—Dysphagia is increasing. Pulse 80. Twelve leeches were applied to the temples. To have one drop of croton oil every four hours. Feb. 9.—Breathing more hurried and labored. Pulse 116, small and weak. Bowels freely opened by the croton oil. Appeared to feel the bites of the leeches. This morning he had a return of the general convulsions, more severe, and lasting for a longer period than the former; accompanied with frothing at the mouth. Feb. 10.—Last night, about 8 p.m., he began to moan and cry out, but no convulsions. The respiration * Reported by Mr. Cunningham, Clinical Clerk. CEREBRAL HEMORRHAGE. 409 became more labored, and accompanied by a tracheal rale. At 12 p.m. he died comatose. Sectio Cadaveris—Thirty-six hours after death. Head.—On removing the calvarium, the sinuses of the dura mater were found almost empty; the longitudinal one contained a small decolorised coagulum. The cerebral arachnoid was very dry, the surfaces of the hemispheres flattened, and the convolutions pressed together. The ventricles were distended by 13 drachms of colorless limpid serum, and freely communicated with each other by means of the foramen of Monro, which was much enlarged. The fornix, septum lucidum, floor of the fourth ventricle, and corpus callosum, were of pultaceous consistence, and readily broke down under the fingers. On removing the brain, a semi-opaque exudation of yellowish-white color was seen in the subarachnoid space at the base of the brain, extending to the sylvian fissures laterally, surrounding the chiasm of the optic nerves anteriorly, and stretching as far back as the fifth pair posteriorly. Here, however, the coagulated exudation was very thin and soft, whereas immediately behind the optic commissure, it was one-eighth of an inch thick, and of considerable density. On slicing the optic thalamus from above downwards on the right side, there was dis- covered below that ganglion, in the crus cerebri, a clot of dark-red blood the size of a pea, surrounded by several smaller red spots, the result of capillary hemorrhage. Tho cerebral substance surrounding it was softened to the extent of a quarter of an inch all around. In the pons varolii, two masses, the largest the size of a millet seed, of yellowish indurated chronic exudation, were discovered. Chest.—Pleura? of both lungs were adherent at the apex, especially on the left side. The lining membrane of the bronchi appeared congested, and of a reddish color. The bronchial glands were loaded with pigment. A cavity was broken into, when separating the dense adhesion at apex of left lung, and a dirty greyish white, tolerably tenacious, fluid escaped. This cavity was capable of holding a hen's egg. Walls were irregular, and lined by no distinct membrane. The surrounding texture was of a deep red color, and displayed on section numerous yellowish hard miliary tubercles. These were also found scattered over the lower part of the left lung. The right lung was crepitant throughout, and displayed here and there on section the same bodies as above described. Abdomen.—Numerous yellowish miliary tubercles were found in the cortical and tubular portions of both kidneys. Other viscera healthy. Microscopic Examination.—The exudation at the base of the brain was composed of bands of molecular fibres, mingled with curled and spiral elastic filaments. In the softer parts of the exudation, the delicate molecular fibres at irregular intervals con- tained nuclei, most of which were oval, and a few fusiform. The centre of the clot in the crus cerebri was composed of numerous blood corpuscles, and the surrounding softened cerebral substance contained numerous granules and granular cells. The serum in the ventricles was structureless, and the cerebral softening of the white sub- stance contained no granule cell3, the normal structure being only more easily separ- ated and capable of being broken up when crushed between glasses. Commentary.—This is an instructive characteristic case of that form of apoplexy which has been called ingravescent, commencing with head- ache, followed by temporary loss of consciousness and voluntary motion, then recovery, and, after a period varying from a few hours to several days, gradual return of the coma, almost always followed by death. Such return of coma is usually the result of gradually increasing pres- sure on the brain, but the pathological cause of that pressure is not always easy to determine. Most commonly it is the result of a hemor- rhage slowly increasing, and at length forming a large coagulum. Occa- sionally it is caused by an effusion of serum into the ventricles, and a few cases have been observed where it was the effect of a congestion which either might or might not leave traces after death. In the present case we found four lesions of the nervous structure—1st, Chronic exudation at the base of the brain ; 2d, A hemorrhagic clot in the right crus cerebri; 3d, Accumulation of serum in the lateral ven- 410 DISEASES OF THE NERVOUS SYSTEM. tricles; 4th, Softening of the central structures of the brain. Of these lesions the three first doubtless united in producing the symptoms, whilst the last was post-mortem, dependent on imbibition of the serum after death. Here it is important to observe, that the exudation of the base was chronic, for in structure it was firm and fibrous, characters which I have never seen in recent exudations into the subarachnoid cavity, which are generally purulent. It is exceedingly probable, there- fore, that the headache and premonitory symptoms were occasioned by the meningitis ; whilst the subsequent twitchings and convulsions were attributable to the presence of the exudation, more especially the pressure and irritation occasioned at the base of the encephalon by the subsequent changes through which it passed. Then the apoplectic attack on the 27th was entirely owing to the hemorrhage into the right crus cerebri. This hemorrhage was small in amount, and the apoplectic condition was momentary. It probably, however, increased somewhat afterwards, and broke up the nervous structure of the crus; and the result was interruption of the conducting power between the brain and left side of the body—in other words, hemiplegia. Lastly, the exudation and clot combined must have exercised pressure on the veins, producing dropsy of, or effusion into, the lateral ventricles, whereby was produced a gradually augmenting pressure on the whole organ, occasioning the in- gravescent coma. It may be a question how far the spasms of the jaw were occasioned by the clot in the crus cerebri irritating the deep origin of the motor branch of the fifth, or by the exudation surrounding its superficial origin from the pons varolii. I am inclined to think the first theory the true one, because both divisions of the fifth were alike sur- rounded by the exudation at the base, and yet spasm only was caused, and no pain. The treatment of this case was very carefully considered, the more so as it was the evident opinion of the examining class, and of the clerks, that it should be treated actively by blood-letting. The student and young practitioner is generally an advocate for active treatment; and this was certainly a case in which a difference of opinion might be ex- pected to exist even among the most experienced. The circumstances, however, which forbade general bleeding, were—the condition of his pulse, which, though of good strength, was never full or hard ; the paleness of his countenance, and his general habit of body, which was far from robust. The existence of phthisis did not influence me at the time; but I think it supports the correctness of the conclusion I arrived at. Many years ago, when studying the subject, nothing struck me more in care- fully analysing the cases of Abercrombie, in reference to this question, than the fact, that notwithstanding he waited until the circulation rallied, and the pulse rose, the almost constant statement is, that a full blood-letting produced " no benefit," " no relief, " not the smallest benefit," and so on. And in such cases, when pressure is caused by a solid coagulum or local obstruction to some part of the venous system, inducing effusion, how can bleeding lessen the pressure when the heart's action is not increased? We have already seen that the idea of diminish- ing the amount of fluids within the cranium by bleeding is visionary, and experience fully proves its uselessness, even in the hands of men who inculcate the practice. All agree, however, that you can only CEREBRAL HEMORRHAGE. 411 relieve pressure on the brain by influencing the force of the heart's con- tractions. But in the present case, so far were these contractions from being increased, that they were normal when he was first admitted, and exhibited a tendency to diminish in force. Indeed, so low was the pulse on 4th February, that I administered stimulants, under which he rallied. Looking, then, retrospectively at this case, it appears to me certain that bleeding, by diminishing the force of the general circulation, would have increased the tendency to effusion in the lateral ventricles, and would have hastened rather than retarded the fatal result. Case XXVII.*—Apoplexy—Hemorrhage into right Optic Thalamus, caus- ing Hemiplegia on left side—Progressive Recovery—Two months afterwards, Hemorrhage into Pons Varolii and Membranes on right side—Death in seven hours. History.—Margaret Lockie, set. 57, a sempstress—admitted on the evening of De- cember 8, 1854. A friend who accompanied her said that the patient had been very much addicted to drinking, and had an attack of delirium tremens a month ago, for which she was treated in the Infirmary, and dismissed cured after a week's treatment. She continued well until three days ago, when, sitting in a neighbor's house, she sud- denly fell from her chair insensible. This occurred about five o'clock p.m., without any obvious cause, as at the time she was pursuing her usual employment of sewing. Symptoms on Admission.—On admission, the face presents its natural appearance, and is in no way distorted. The intelligence is much impaired, although she is so far conscious, that when loudly spoken to, she mutters something, and with great effort can articulate indistinctly " Yes," and " No." The eyes are suffused and red; the pupils normal; the right hand and arm are paralysed, though the sensibility is not absolutely gone. Sensibility is also greatly diminished, and motion completely lost in tho right inferior extremity. The left leg is abruptly retracted on pinching it; the left arm and hand unaffected. There has been no convulsion, nor is there any muscular rigidity. She cannot protrude the tongue. State of digestive system cannot be ascertained. Heart sounds normal in character, but weak. Pulse at the wrist 60, barely perceptible. One drop of croton oil to be administered in the form of bolus immediately. A sinapism to be applied to the back of the neck. § iss of sherry wine to be taken every two hours. Progress of the Case.—December 9th.—Is more conscious. Urine loaded with lithates, otherwise healthy. Bowels have not been relieved. December 10th.—Has had a dose of castor oil, and the bowels have been freely relieved twice. Is now so far conscious that she attempts to speak voluntarily, and she can mutter various words. On smiling, it is distinctly seen that the mouth is dragged to the left side, and that the right half of the face is paralysed. She can now also protrude the tongue, which is very foul. Skin of natural temperature. Pulse 68, still weak, but of better strength. Has taken nourishment. To have § iij of sherry daily. From this time she rapidly recovered her consciousness. On the 20th she could readily answer questions, and the mind seemed perfect, but the articulation is still difficult. On the 31st articulation is nearly distinct. January 14th—Paralysed parts still im- movable, but their sensibility has to a great extent been restored. January 25th.— Galvanic currents to be applied to the right leg and arm. February 1st.—Can now move the right arm voluntarily to a certain extent. Right leg still immovable. Paralysis of jaw has disappeared. February 12th.—Had been doing well up to four o'clock this morning, when, after having been assisted out of bed, she suddenly began to moan, and was seen by the nurse to apply her left hand to the head. She was seen by the house physician (Dr. M'Laren) ten minutes afterwards, and was found to be quite unconscious, breathing heavily. The left pupil dilated, the right contracted, and both were insensible to light. All the limbs were powerless, and fell on being raised like inert masses. The respirations rapidly became more laborious and less frequent, and she died at eleven o'clock. Sectio Cadaveris.—Fifty hours after death. Head.—On removing the calvarium and dura mater, the surface of the arachnoid * Reported by Mr. Almeric Seymour, Clinical Clerk. 412 DISEASES OF THE NERVOUS SYSTEM. was observed to be unusually dry. In the right temporal region was a thin extra- vasation of blood, in the subarachnoid cellular tissue. The iateral ventricles con- tained above 3 ij of sanguinolent serum, and communicated freely with each other by means of the foramen of Monro, which was the size of a goose's quill. The right corpus striatum and optic thalamus were healthy, but the left optic thalamus was dis- organised throughout, its centre being occupied by a clot of blood the size of a hazel- nut, dark in the centre, of a brick-red color externally, surrounded by softened cerebral matter of a yellow fawn-color. On removing the brain, the extravasation formerly noticed on the right side was seen to extend downwards over the base of the brain on the right side, and over a portion of each lobe of the cerebellum, forming a thin layer of blood between the pia mater and arachnoid membranes. The arteries at the base of the brain presented numerous opaque patches of atheroma. On cutting into the pons, an extravasation of blood had taken place into its substance, disinte- grating the whole of it; it was of a dark red color, evidently recently poured out, and was fluid in some places, and loosely coagulated in others. Chest.—With the exception of a few atheromatous patches on the aorta and mitral valve, which latter in no way impeded efficiency, the thoracic organs were healthy. Abdomen.—Abdominal organs also healthy. Microscopic Examination.—The softening of left optic thalamus consisted of dis- integration of the tubes ; fatty granules accumulated in the ganglionic cells ; numer- ous granule cells, several tinted of an orange color, and others of a dusky red, were in the immediate neighborhood of this clot, mingled with several crystals of hematoid- ine, and masses of blood varying in tint. The centre of the clots presented a series of laminae of a brownish black color. The broken-up pons varolii was infiltrated with blood corpuscles, and the tubes were more or less disintegrated. Commentary.—In this case circumscribed hemorrhage into the right optic thalamus caused apoplexy and hemiplegia on the left side, from which she was gradually recovering, when an unusual exertion caused a secondary fatal hemorrhage into the pons varolii. Here the primary disease was chronic arteritis, causing brittleness of the vessels. In all such cases too much care cannot be taken to avoid sudden exertion, agitation of mind, and every other circumstance which is likely to pro- duce increased pressure on the blood-vessels. Case XXVIIL*—Five years before admission, Hemiplegia, followed by Recovery—Four months before admission Apoplexy, with convidsions and Partial Recovery—Pulmonary Disease—Death by Asphyxia— Chronic Softening of Right Corpus Striatum—More recent Hemorrhage into the Pons Varolii—Cardiac Hypertrophy, with mitral constriction —Hemorrhage into the Lungs. History.—Mrs. Macpherson, set. 34, admitted December 22, 1850—of intemperate habits. She has been troubled for the last four years more or less with cough. Five years ago she had an attack of paralysis affecting the left side of whole body. Her speech was thick. The left cheek appeared more prominent than natural; there were twitchings also of the left arm. Leg not affected. Intellect unimpaired. She recovered perfectly in two or three months. She continued, however, her intem- perate habits, and was addicted to taking laudanum. Four months ago, after taking a drachm of laudanum, she was suddenly seized with violent convulsions, sprang a little distance, and fell on her face. She was quite unconscious at the time, a condi- tion from whieh she gradually emerged, but her mind has ever since been affected, and the power over the left side is much impaired. Since the second attack, she has been subject to violent and sudden fits of coughing, lasting for hours without inter- mission, which have latterly increased. Symptoms on Admission.—On admission, she leans to the right side when sitting. Countenance anxious, motions of chest rapid, with much elevation of thorax during inspiration. Dyspnoea urgent. Cough constant and paroxysmal. Expectoration copious. On percussion the anterior surface of the chest sounds resonant. There is dulness over the infra-scapular region of left side. On auscultation, the inspiration * Reported by Mr. Pearse, Clinical Clerk. CEREBRAL HEMORRHAGE. 413 is short and the expiration much prolonged, and accompanied with sibilant and sonorous rales over the whole anterior surface of both sides; loud crepitating and mucous rales over the inferior portion of left back, with distinct crepitation also inferiorly in right back. Vocal resonance is increased over left infra-clavicular region. Heart's sounds normal, distant. Tongue of a brown color, moist. Appetite bad. Bowels' regular. Catamenia regular. Has no pain in head or any part of her body. Skin hot and moist. Progress of the Case.—December 30th.—She has been treated with various anodyne expectorant mixtures, sulphuric and nitric ether, ipecacuan wine, chloroform, morphia, etc., to relieve the cough and difficulty of breathing, but with little benefit. Is weaker to-day. Countenance sunk and anxious. Tossing about of arms.^ Breath- ing short and rapid. Cough almost ceased. Expectoration greatly diminished. Pulse weak, scarcely perceptible. Ordered two ounces of whisky and one pint of porter daily. January 1st—Exhaustion still greater. With difficulty roused to answer questions; incoherent in her conversation; sleeps little; breathing rapid, short, and labored; paroxysmal cough. The rales formerly noticed still continue; dulness over the left back more extensive and complete. Pulse small. Habeat Spirit. commun. § iv. January 2d.—Since yesterday there have been coldness and lividity of face, with stupor gradually increasing. Dyspnoea very urgent. Expectoration scanty. These symptoms increasing, she died at 3 a. m., January 3d. Sectio Cadaveris.—Nine hours after death. Head.—The dura mater and arachnoid membrane were healthy in structure, but the subarachnoid cavity contained superiorly a small quantity of serum between the sulci. Both lateral ventricles contained about a drachm of fluid, but that on the right side was opaque, of a greyish color like dirty milk, while that on the left side was colorless and clear. Three-fourths of the right corpus striatum posteriorly was reduced to a fawn-colored diffluent pulp, from which a turbid grey fluid flowed out on puncture, similar to what had tinged the serum in the ventricle. The white substance external to the corpus striatum was not affected, the lesion being limited to a space about the size of an almond nut. On cutting through the softened texture, a few bright yellow patches were observable, about the size of a millet seed, closely resem- bling in appearance the reticulum often seen in soft cancer. On slicing the pons va- rolii, there was observed near its centre, a little to the right of the median line, a he- morrhagic extravasation the size of a small pea, the centre of a dark red, and the cir- cumference passing into a rusty brown. Other portions of the encephalon were healthy. Chest.—The left ventricle of the heart was somewhat hypertrophied, the apex rounded, the mitral orifice was smaller than usual—just admitting the thumb—but there was no thickening or disease of the lining membrane. Lining membrane of the heart and large vessels stained of a claret color—blood fluid. Both lungs anteriorly emphysematous. The lining membrane of the bronchi of dark mahogany color, and more or less filled with sanguinolent mucus. Inferior lobe of left lung greatly engor- ged, containing coagulated masses of extravasated blood, varying in size from a pea to a moderate-sized orange. Inferior lobe of right lung also engorged, with similar masses of blood, but not so numerous nor so large as on the opposite side. Abdomen.—Abdominal organs healthy. Microscopic Examination.—The turbid fluid in the right ventricle of the brain contained numerous floating granular cells and masses. The softened portion of the corpus striatum was infiltrated with them throughout, and the bright yellow masses were composed of an aggregation of the same cells and masses mingled with innumerable molecules and granules. The clot in the pons varolii contained several round and oval celloid bodies, varying in size from the four to the six hundredth of an inch in diameter, crowded with blood corpuscles (Fig. 316). No granular cells were any vhere visible in its neighborhood. Commentary.—The history of what occurred to this woman previous to her admission, involving the account of the two paralytic seizures, was obtained after her death from the husband, who attended the post-mortem examination. During the period she was under treatment, the pulmonary symptoms were those that excited chief attention. The weakness stated to exist on the left side of the body was certainly very slight, as, in the frequent examinations which occurred, it was observed that she sat up 414 DISEASES OF THE NERVOUS SYSTEM. when desired to do so, presented either hand when bid to have the pulse felt, and frequently got out of bed without assistance. The crepitating and mucous rales, with the dulness of percussion and great prostration of the patient, however, left little hopes from the first of her recovery; and of these symptoms she alone complained, never speaking of a former or a present palsy. These facts in themselves are very curious, when com- pared with those narrated when the brain was examined, although here it must be confessed that the investigation of the nervous phenomena, from the dislike to interrogate closely a woman evidently dying, was not very minute. There can be little doubt that the first attack was owing to disease (perhaps a hemorrhage into the right corpus striatum) five years previously, and the second, four months before admission, to the limited hemorrhage into the pons varolii. Case XXIX.*—Three attacks of Apoplexy—The first dependent on He- morrhage into the right Corpus Striatum, in May 1861; the second on Hemorrhage into the left Cerebral Lobe and right Optic Thalamus, November 1861; and the third on Hemorrhage into the Arachnoid Cavity, March 1862. Atheroma of the Blood-vessels—Hypertrophy of Heart—Chronic Disease of Lunys, Liver, and Kidneys. History.—John Gow, set. 56, hawker, was brought to the hospital March 12, 1862, by strangers who found him insensible on the road near Penicuick. His wife gives the following account:—Previous to the month of May 1861, he had been a strong and healthy man. At that time, when walking, he suddenly, without any cry, fell down insensible. He had no convulsions, but foamed slightly at the mouth. When he recovered his consciousness he was able to walk, but the left leg was dis- tinctly dragged after him. His mind was at this time unimpaired, but his speech was altered and hesitating. From this period till November last he remained in much the same condition, when he had another fit, again falling down quite insensible. He foamed at the mouth, and bled from the nostrils. He remained insensible for several hours. On becoming conscious, both legs and arms were paralysed. He was for six weeks confined to bed, during which time his mind has been impaired. The speech was rambling and not to be understood, either as regards sense or articulation. He asked for nothing, but was constantly muttering. Deglutition has been unimpaired, but it was necessary to feed him with a spoon. In May 1862 he was able to get up and walk about a little, but dragged both his legs, and the arms hung listlessly at his side. On March 10th, having previously confined his walks to about the door of his house, he contrived, unknown to his wife, to reach Penicuick, seven miles from Edinburgh. How she does not know. She heard nothing further about him till she discovered he was in the Infirmary. Symptoms on Admission.—He is able to understand and answer questions in monosyllables. He is drowsy, and like a person in a state of collapse. He moves his arms and legs freely in bed, when asked. Sensibility is unimpaired. The muscles on the right side of the face are more contracted than on the left. The tongue is pro- truded straight. Appears depressed and exhausted. Whole surface cold. No oedema. His pupils are slightly contracted, but they obey the stimulus of light. Dis- tinct arcus senilis in both eyes. Considerable emaciation. Slight cough. No dyspnoea. No expectoration. Respirations, 12 per minute, not labored nor stertorous. Respiratory murmurs harsh. Percussion resonance over the chest less clear than natural posteriorly. Pulse 66, weak. The second sound of the heart is clear and ringing. Radial artery corded and tortuous. Tongue covered with a dirty white fur. Deglutition unimpaired. The urine dribbles away in bed. A catheter was passed, and about half an ounce of urine was obtained. It was albuminous and contained fatty and granular tube-casts. Habeat Pulv. Jalap. Co. statim 3 i; et Haust. Senna; § ij, post tertias horas. To be dry-cupped over the loins. Half a pint of strong beef- tea to be given, and hot bottles applied to the extremities. * Reported by Mr. R. B. J. Cunynghame, Clinical Clerk. CEREBRAL HEMORRHAGE. 415 Progress of the Case.—Five p.m. Surface still cold, pulse very feeble, 50 per minute. To have wine 3 i every hour, with strong beef-tea. In the evening, brandy Z ss every hour was administered. March 13th.—Has passed urine freely in bed and at stool since; he was cupped yesterday. Bowels were moved this morning. Warmth has returned to the surface. Just before visit to-day, he passed nine ounces of urine which was highly albuminous, and contained fatty and granular tube-casts, with urates and phosphates in excess; pulse 56, rather stronger; takes food well. R Potass. Bitart. 3 ss ter in die cyatho aquce. Beef-tea and wine to be continued. March 14lh.— In much the same condition. Got out of bed last night, and was able to stand leaning against a pillar. He fell in making the attempt a second time. Drowsiness continues. Emplast. Lytlai nuchm applicandum. Marchl5th.—Appetite good. Pulse 72. Tongue hard and dry, covered with sordes. He is quiet, and sleeps well. Pupils immobile to light. Brandy ^ iv daily. March 11th.—Tongue very dry. There is great fetor of the breath. Pulse 60, very feeble, intermittent. Evacuations passed in bed. Urine free from albumen. March 20th.—He is very weak. Pulse 76, irregular, intermit- tent. He has not slept well. Appetite failing. From this date the patient gradually r.:;nk. He became insensible on the 23d, and died at 4 p.m. on the 24th. Sectio Cadaveris.—Twenty-one hours after death. Body emaciated, looks older than assigned age. Costal cartilages ossified. Head.—On removing the calvarium and dura mater, there was found on the right side a good deal of subarachnoid effusion, and the membrane was rather thicker and more opaque than natural. In the cavity of the arachnoid, over the left hemisphere, was a layer of blood of a brownish red color, and almost entirely fluid, which gravi- tated to the posterior part of the left hemisphere. The quantity amounted probably to about half an ounce. One small patch had coagulated, but was not at all decolor- ized, and was adherent to the surface of the hemisphere, rather anterior to its middle and very near the median fissure. Oa slicing the brain there were found more red spots than natural in the medullary portion, and it was noticed that the vessels near the surface were unusually rigid, several of them standing out and remaining open after being cut. The substance of the brain was somewhat cedematous. The lateral ventricles were much dilated. Each contained an ounce of clear serum. The foramen of Monro was the size of a sixpence. When the brain was removed, it was found that the hemorrhagic extravasation on the left side extended down to the base, where, in the middle and posterior fossaa of th.3 skull, it formed a layer about an eighth of an inch in thickness, and appeared rather inspissated than coagulated. In fie anterior third of the left hemisphere, a portion of the grey matter of some of the convolutions, and the adjacent white matter wa3 slightly softened, and of a faint yellowish calor. Oa slicing the brain an old apoplectic cavity was opened into at this point. It was of an irregularly crescentic form, one and a quarter inches in length, by half an inch at its broadest part, very shallow, and containing a soft matter of a russet brown color. It was situated on a level with tin upper surface of the corpus cal- losum, and was close to the surface of the brain. The hemorrhage had evidently taken place from the vessels in the grey matter of the convolutions. The cavity was found to be lined by a thin but tough membrane The lining membrane of the right lateral ventricle was thickened, and a slight depression with a brownish yellow coloration of the margin existed at the posterior part of the optic thalamus. On cutting into this part, the cerebral matter did not appear to be affected, but the lining membrane of the ventricle was thickened there, and infiltrated into and below it was some yellowish matter. On cutting into the right corpus striatum there was found in its centre a small apoplectic cyst, about the size of a field-bean, having a distinct lining mambrane, and containing a russet brown matter. Other parts of the brain were natural. There was considerable atheroma of the arteries at the base of the brain. This was especially the case with the branches in the fissure of Sylvius, many of which were of an opaque color, having quite lost their transparency. Their coats were thickened, but contained no calcareous matter. T.iorax..—The heart was enlarged, weighing 15i ounces. The valves were natural, and the hypertrophy was entirely due to increased size of the left ventricle, t.ie cavity of which was a little dilated, while its walls were much thickened. The ng.it ventricle was of normal dimensions. The aorta was atheromatous and cal- careous just above the semilunar valves. The remainder of the vessel was but slightly a.Fjcted. There were old adhesions at the apex of each lung corresponding to puckerings and cretaceous concretions in the pulmonary tissue, and slight emphysema 41G DISEASES OF THE ^ERVOTTS SYSTEM. of the anterior margins of the lungs. The bronchi contained mucopurulent matter, :v„:d the mucous membrane was much congested. Abdomen.—The liver weighed 2 lbs. 8 oz., the capsule was slightly thickened, and harder than natural. The kidneys were very small, weighing together 3£ ounces. The capsule was removed with difficulty. The surface of the organs was tolerablj smooth, but had a somewhat rough indurated feeling. The vascularity was pretty regular and normal. There were no opaque granulations, but two or three small cysts were visible. On section much fat was found in the pelvis of each kidney. The cortical substance was atrophied, forming a thin line around the surface of the organ. Microscopic Examination.—The contents of the cavity in the left hemisphere were found to consist of granular matter, yellow granular pigment, and remarkably well-defined ci'ystals of hajmatoidin. The lining membrane presented an obscurely fibrous and rather fibrillated appearance, having quite the structure of an old clot. Immediately external to the cavity was a patch of fawn-colored softening, of the size of an almond, in which very numerous granular corpuscles were found, as well as granular matter and some blood globules. The softening of the right optic thalamus presented exactly the same structure. The small cyst in the right corpus striatum contained nothing but purely molecular matter. In the kidneys the amount of fibrous tissue was everywhere increased. The capsules of the Malpighian bodies and the coats of the vessels were thickened. Very numerous cysts of all sizes were seen, in most of which the lining of epithelium was distinctly visible. The tubes were contracted and seemed fewer than natural. The tube-casts in the urine were small. The epithelium also was granular, but there was little fat. Commentary.—This is a very instructive case of cerebral hemorrhage occurring at three distinct intervals, causing characteristic symptoms on each occasion, and leaving decided proofs of their occurrence after death. The first attack in May 1861 was sudden, and he recovered with his mind unimpaired, but with dragging of the left leg. This was evidently dependent on circumscribed hemorrhage into the right corpus striatum, the remains of which after death exhibited the form of a small cyst, with a distinct lining membrane, containing a brownish molecular matter. That is, the small clot was transformed in the manner described in a period of ten months. The attack in the following November was more severe, and on his recovery both legs and arms were paralysed. His mind also was gravely affected, and he could not articulate. On this occasion hemorrhage must have occurred into the optic thalamus and ventricle on the right side, and into the anterior cerebral lobe on the left side, thus accounting for the paralysis on both sides of the body, and the disturbance of mind. The microscopical examination also proves that both these hemorrhages were of the same date, for though on different sides of the brain, they each contained numerous granule cells and crys- tals of haematoidine. The third and fatal attack was evidently caused by the recent hemorrhage into the arachnoid cavity. Whether this was caused by a fall, cannot be stated with certainty, as no contusion could be found; but considering his state of weakness, and that the mental hallucination under which he labored, induced him to drag himself seven miles from his residence, it is by no means improbable. The atheromatous condition of the cerebral blood-vessels, and condition of the heart, lungs, liver, and kidneys, present a complication of diseases, all of which predispose to fatal apoplexy. The predisposing cause of cerebral hemorrhage is, in the vast majority of cases, previous disease and consequent brittleness of the arteries. It is true there are some rare instances in which it cannot be traced to this circumstance, and where its origin is obscure (Case XXIV.),.or where in young persons, or those of middle age, it may originate from obstruction CEREBRAL HEMORRHAGE. 417 of the vessels by clots sent from a distance, as previously explained. Still, even in these, and in the great majority of individuals advanced in life, among whom apoplexy and sudden palsy are common, chronic cere- bral arteritis may be considered as the real disease, and hemorrhage as its result. Hence why all those circumstances which induce increased pressure on the internal surface of the arteries are the proximate causes of apoplexy and sudden palsy, such as violent exertion, constipation, straining at stool, strong drinks, undue repletion at meals, mental emo- tions, etc. etc. The histological facts ascertained in connection with the hemorrhagic clot are important. The colored blood corpuscles at first accumulate in groups, and some of them are subsequently surrounded by a celloid membrane. Under such circumstances they slowly disintegrate ; the red color is changed into a brown, which becomes darker and darker, and is ultimately converted into black. Not unfrequently crystals, supposed to be of hematine, are scattered among the broken-up clots, and have been seen both of a deep-red and black color even within the membrane alluded to. That this membrane really does form in the manner described— that is, secondarily—around heaps of blood corpuscles, I am satisfied—my former assistant, Dr. Sanderson, having proved it by direct experiments in my presence. He thrust a needle through the cranium into the cere- bral lobes of four pigeons which were killed, and the brain inspected, successively on the third, fifth, and sixth days. There could be observed in one case, where a slight hemorrhagic streak marked the track of the pin, that the cerebral substance, seen under a magnifying power of 250 diameters linear, contained groups of from five to twelve oval blood cor- puscles, each surrounded by a delicate membrane. (See Fig. 317, p. 248.) When the clot is large, this process may go on through its entire sub- stance, in conjunction with the formation of compound granular cells. I examined a tumor the size of a small hen's egg, brought to me by Dr. Peddie,_ in which the external layer presented numerous fibre cells and fibres, in various stages of development, whilst the interior was prin- cipally composed of numerous granules and compound granular cells. Here and there, however, were patches of red extravasation more or less Fig. 410. Section of the capsule and portion of the coagulum, size of an orange found in the brain in Dr. Erkwood's case, a, External portion of capsule, consisting ot fibrinous lamina}; b,. internal portion of capsule, rendered dark-red purple and opaque, from condensed blood corpuscles; c, broken-down blood corpuscles in the in- terior, with crystals of cholesterine. 250 diam 27 418 DISEASES OF THE NERVOUS SYSTEM. recent, containing large delicate vesicles filled with blood globules. (See Fig. 316, p. 248.) In another tumor sent me for examination by Dr. Kirkwood of Berwick,* which was the size of a large orange, and im- bedded in the right cerebral hemisphere, I found it to consist of a firm resistant shell or capsule, about one-eighth of an inch thick, containing coagula of blood of a brick-dust color. The capsule, externally, was of a straw color, like that of coagulable lymph; but one-third of its thickness, internally, was dark red passing into black. A small portion of the ex- ternal layer of the capsule, examined under the power of 250 diameters linear, presented apparently a dense mesh-work of fibres, running iu waved bundles, which in fact were th« edges of laminae. The thicker in- ternal layer was composed of siaiikr fibres, mingled with masses of blood corpuscles, in various stages of disintegration. The internal coagula were composed of numerous molecules and granules, and a mass of blood corpuscles, diminished in size, and variously altered in shape, but still presenting their normal yellow hue, mingled with numerous crystals of cholesterine. These and numerous other examinations have convinced me that when the hemorrhagic extravasation is small, it breaks down and disintegrates in a period varying from three to six months. Even then it may leave traces of its existence, especially in the form of a cyst, the internal membrane of which is of a bright orange, or brick-red color. On examining this membrane, or the colored softening in its immediate neighborhood, it may be seen to consist of numerous molecules and granules, sometimes associated with fragments of the nerve-tubes. There are also granular corpuscles and masses, variously tinted, of a bright orange, brick-red, reddish-brown, or dark brown. The former are evi- dently the celloid bodies formerly described and figured (Fig. 317), con- taining blood corpuscle in different stages of disintegration. There are also fre- quently present a greater or les3 number of crystals of hematoidine, of a deep red or ruby tint (Fig. 349). If the clot be large, the period required for absorption may extend to years, and then the ex- ternal portions of the clot are trans- formed into an external fibrous cyst, within which the blood is very slowly disintegrated and absorbed. Most com- monly, however, in these cases, long be- fore absorption occurs, secondary changes take place in the surrounding nervous structure, or pressure is exercised on parts at the base of the cranium, whereby convulsions, paralysis, or other symptoms occur, and life is destroyed. The diagnosis of cerebral hemorrhage from the other lesions of the brain is not always easy, in consequence of the fact that a chronie cere- britis may proceed imperceptibly, and then induce apoplexy or sudden * Monthly Journal, March 1851. Fig. 411. Granular corpuscles and masses, of a bright orange and pale yellow color, some of them passing into brown, with crystals of hematoidine from an old apoplectic clot. 250 diam. Fig. 411. CEREBRAL HEMORRHAGE. 419 palsy. It may generally be observed, however, that a true exudative cerebral softening is preceded by more or less weakness of the intellect, and more especially by slowness in receiving mental impressions, or framing replies to questions, frequently combined with more or less headache, confusion of ideas, and perversion of motion. Much will de- pend upon the seat of the lesion, the mind being disordered most in pro- portion to the extent and nearness of the disease to the hemispherical ganglion—while motion is the more influencad, according as the central and basic parts of the brain are affected. Then it should not be forgot- ten that whilst a cerebral softening may occasionally lead to or be com- plicated with a hemorrhage, so a hemorrhage is one of the most common causes of a softening. The distinction between the two under such cir- cumstances becomes very difficult. Still there can be no question that suddenness of attack, whether of apoplexy or of palsy, is (excluding ex- ternal injury) the characteristic symptom of cerebral hemorrhage. Occa- sionally, however, sudden paralysis makes it3 appearance in cases of chronic softening, a result which Dr. Todd has attributed to the rupture or deliquescence of tubes which had been already softened, but not suffi- ciently to interrupt their power as conductors of the nervous force. Whether hemorrhage be consecutive on diseased arteries, or upon their calibres being obstructed by clots, must be determined from all the facts of the case; the former being most likely in elderly, and the latter in younger persons with diseased hearts. Little, however, is as yet under- stood of this point diagnostically in the living subject. For what is known with regard to the seat of cerebral hemorrhage and softening, I must refer to page 152. The influence of cerebral softening and hemorrhage on the motor function has justly excited the attention of physicians. Whilst by some more or less contraction and rigidity of the limbs have been considered as highly characteristic of inflammatory softening, others have maintained that it is altogether incidental, that it often exists when no softening can be found, and that it is as often absent when softening is present. It has also been known to accompany hemorrhages, apparently unconnected with softening. The analysis of many cases in reference to this subject has led me to the conclusion, that on the whole muscular rigidity or con- traction is a valuable sign of softening when present, but that, as the softening may be permanent, whilst the rigidity is only temporary and indicative of the irritating effects of the lesion, the absence of the one is no proof of the non-existence of the other. It should be remembered that much of this discussion took place formerly when no means were known of distinguishing histologically between inflammatory, hemorrhagic, and post-mortem softenings. Dr. Todd has especially drawn attention to the state of the muscles in palsied limbs from cerebral disease,* arranging the cases into three classes —1st, Those in which the muscles of the paraly- tic limbs are completely relaxed; 2d, Those in which the paralysed muscles exhibit rigidity from the moment of, or soon after, the attack; 3d, Those in which rigidity comes on long after the paralysis. The first class of cases he considers usually results from hemorrhage, combined with previous softening of the brain and rupture of the tubes, the clot of * Clinical Lectures on Paralysis, etc. 1854. 420 DISEASES OF THE NERVOUS SYSTEM. blood being separated from healthy brain. The second class of cases depends on the clot of blood acting directly on sound brain at the point of implantation of the nerves of the affected muscles; while the third class of cases are owing to a similar irritation from an attempt at cicatri- zation of the brain's substance. These views of Dr. Todd, though in- genious, must as yet only be regarded as probable speculations. The true generalization appears to me to be, that complete paralysis indicates such pressure on or obstruction of cerebral tissues as to prevent all trans- mission of nervous influence, whilst rigidity, convulsion, and pain show that some tubes of that tissue are preternaturally excited. Both condi- tions may be occasioned by hemorrhage, exudation, effusion, tumors, or any lesion that affects the brain. The treatment of cerebral hemorrhage must refer to the attack, and to the subsequent management of the case. At the moment of attack, the steps to be pursued must always be a subject of anxious considera- tion. Formerly there was little difficulty—venesection to a large ex- tent being the established routine remedy. The advance of pathological knowledge, however, must have made it apparent, that the same pro- ceeding is not likely to be beneficial in all cases where the nervous centres are similarly affected. We may have sudden loss of conscious- ness and volition from syncope, as well as from coma, the only supposed difference between the two being, that the same nervous phenomena commence in the heart, with a weak pulse, in the one case, whilst they originate in the brain, and have a strong pulse, in the other. But care- ful observation has sufficiently proved that there are many cases of even true hemorrhagic apoplexy which are closely allied to syncope, and which have recovered under the use of stimulants, rather than of deple- tions. It seems to me also very probable that many of those individuals who died under what Abercrombie called simple apoplexy, and in whom no trace of disease could be found in the brain after death, were really the victims of one form of fatty degeneration of the heart—an affection in his day altogether unknown. The best rule, therefore, I can give you, is to judge from all the circumstances of the case. Whenever the individual is of vigorous frame of body, if the face be flushed, the attack recent, and the pulse strong and full, a moderate bleeding may be bene- ficial. The extent must be influenced by its effect on the heart's action; for as we have seen, the object of this measure is not to draw blood from the brain, which is impossible, but to diminish the pressure on that organ, by lessening the force with which the heart propels the blood through the carotid and vertebral arteries. On the other hand, if the individual be of spare habit, the face pale, the pulse weak and irregular, and the usual symptoms of shock be present, wine, brandy, stimulants generally, and restoratives, are demanded. But it most frequently happens, that when you are called in, neither one nor the other indica- tion presents itself. It will be most prudent, under such circumstances, simply to apply cold to the head, administer an active purgative, and above all enjoin quietude. At the same time the patient should be placed in the horizontal position, with the head slightly elevated, whilst the cravat, stays, and all impediments to the respiratory and circulatory functions should be removed. CANCER OF THE BRAIN. 421 Should the individual recover from the attack, quietude, mental and bodily, and supporting the economy by good nourishment, constitute the chief treatment. Thus long conversations, literary labor, business transactions, the sudden reception of joyful or distressing intelligence. etc., should be carefully avoided. Sudden exertions, rising from bed (see Case XXVII.), constipation, straining at stool, etc., must be guarded against. Of all these I believe the prevention of constipation to be the most important, as the straining at stool thereby occasioned is one of the most common causes of secondary attacks. If paralysis remain, considerable caution must be exercised before having recourse to local stimulants, such as frictions, galvanism, or exercise of the t affected parts. These are remedies of undoubted utility, but never to be employed at the risk of causing general excitement, and always very gradually applied, and their increase well regulated. Exactly the same management is required in cases of chronic cerebritis, or where there is reason to suspect that coagula from the heart constitute the cause of the cerebral lesion. CANCER OF THE BRAIN. Case XXX.*—Cancer of the Brain, Spinal Cord, Liver, and Bones. History.—George Gall, set. 29, a stoker on board a steam-vessel—admitted July 1, 1857. About the beginning of December 1856, he contracted a cold with cough and profuse expectoration, and has not since enjoyed good health. At the end of March 1857, he began to feel pain in the lumbar and sacral regions, extending also to the neck, affecting the shoulders, and spreading down to the joints and muscles of the arms. The knee-joints were also painful. They are reported to have been swollen, but only for a short time. At the commencement of last April, he seemed to labor under confusion of thought, with shortness of memory, and incapability of carrying on a train of ideas. During the next two months became gradually more weak and emaciated; at length he was unable to walk or to rise unassisted; passing his urine in fair quantity, but involuntarily during sleep. Symptoms on Admission.—Has no headache; is very silent, but listens to ques- tions, and answers them after a slight pause intelligently. The questions, however, require only monosyllabic answers. He says little, and his»thoughts are apparently few. Special senses normal. The pupils are unusually dilated, but contract on stimulus of light; are equal and parallel. No paralysis of the muscles of the face or tongue. Marked tenderness over dorsal, and still more over lumbar vertebrae. Never had tingling or numbness of the extremities. All attempts to walk cause great pain in the back, to such a degree that he cries out. Great atrophy of the muscles ; he moves very little; lies often in a cramped position; cannot rise up in bed without assistance. The tongue is clean; the appetite is reported to be good; but he fre- quently vomits, sometimes immediately after a meal, sometimes an hour or two after- wards. No increase in hepatic or splenic dulness; abdomen appears natural, except in being retracted and emaciated; the bowels are habitually costive. He has at pre- sent no cough, sputum, nor dyspnoea. The respiratory murmurs appear healthy; the cardiac sounds are natural. Pulse 82, small and weak. The urine is passed involun- tarily during sleep, but voluntarily during the day. It is of a light straw color, sp. gr. 1005; contains no albumen but abundant chlorides. Is ordered nutritive food, with laxative pills, and, if necessary, enemata. Progress op the Case.—July 6th.—Is growing weaker; pulse 96, small and wiry; has a headache, chiefly over the occipital region. July 9th.—The pain in his head continuing, the hair is shaved; cold cloths are applied to the scalp, and a blister is put over the nape of the neck. July 10th.—Pulse 104, very weak; hot skin; great thirst; little appetite, and frequent vomiting, usually some time after taking food. Is ordered a saline mixture, and four ounces of port wine daily. July 12lh.— * Keported by Mr. John R. Murray, Clinical Clerk. 422 DISEASES OF THE NERVOUS SYSTEM. On re-examination, besides the atrophy common to both lower extremities, there appears to be almost total want of sensibility and motion in the right leg; the left leg being, for one so emaciated, quite normal. Pupils continue widely dilated; there is no headache at present. July 14th.—Is able to move the right leg slightly, and feels irritants applied to the sole of the foot, but not to the limb generally. Again complains of pain diffused over the whole occiput; pulse 112, weak. July 18th.__ Complains of his vision becoming impaired; can recognise objects, and name their number. Had an evacuation yesterday morning, and for two days has not vomited so much as formerly. Has headache, but it does not seem severe; the application of cold has been continued. July 19th.—Pulse 148, small, weak, and hard. Respira- tion 22 per minute. Ordered two additional ounces of wine; continue nutrients. July 21st.—Vomiting recurred yesterday, after being nearly absent for a week; is observed to recur when the bowels have been much confined, and to disappear after copious evacuation. Ordered two pills, and, if necessary, an injection. July 29th.— Vomited less after operation of the laxatives; is extremely weak, but little change can be noticed from day to day. July 30th.—This morning he was found more ex- hausted ; a cold sweat over the whole surface; the respirations short and hurried; the pulse extremely feeble, cardiac impulse at apex increased. Wine was freely given, but he sank, and finally expired at 2.30 p.m. Sectio Cadaveris.—Forty-eiyht hours after death. Body moderately emaciated. Head.—On removing the dura, mater, the surfaces of the hemispheres were unusually smooth, from flattening of the convolutions. The vascularity of the membranes was normal. On slicing the brain it was seen to be studded throughout with nodules varying in size from a hemp-seed to that of a large hazel-nut. They were of a grey, pinkish color—the smaller of pulpy consistency, ihe larger more firm, and all capable of being easily enucleated from the surrounding brain substance. None of them projected from the surface, but they were irregularly distributed, some in the grey, but most in the white matter. Here and there was slight softening round some of the masses, but there was no extravasation of blood. In the right hemisphere, projecting a little through the roof of the ventricle, was a mass the size of an ordinary marble. In the roof of the left ventricle was another of similar dimen- sions. The left corpus striatum contained two of these bodies, one the size of a small cherry, situated anteriorly; another that of a pea, somewhat more posteriorly. Around these was no softening. The optic thalami were normal. Similar bodies were scattered through the cerebellum, but there were none in the pons varolii and medulla oblongata. Each lateral ventricle contained almost a drachm and a half of clear fluid. On removing any of these bodies, there could readily be squeezed from them a creamy matter, leaving behind art apparently membranous substance evidently very vascular. Spinal Column.—The four upper dorsal, and two or three of the lower dorsal, and the first lumbar vertebrae, were soft and spongy, the osseous substance yielding on pres- sure a copious, thick, greyish juice. The membranes of the cord were healthy. On bi- secting the cord, a mass the size of a pea, exactly similar to those observed in the brain, was found in its right half, opposite the junction of the second and third dorsal vertebra?. Chest.—About the centre of the sternum was a slight bulging, of reddish color and soft consistence, yielding a dirty yellow colored cancerous juice on pressure. Similar soft enlargements were found in the anterior portions of the third and fourth left ribs. The lower lobe of right lung contained an infiltrated indurated mass, about the size of the fist, in some places of a yellow brown, and in others of a dirty grey color. Some bronchial glands cancerous. Other thoracic organs healthy. Abdomen.—Liver contained small, rounded, dirty white masses, principally at its circumference, varying in size from a small pea to that of a horse bean, and not pro- jecting from its surface. Some of the gastro-colic glands were enlarged and cancerous. Other abdominal organs healthy. Muscular System, wherever examined, and especially in the inferior extremities, was atrophied, but presented its normal color. Microscopic Examination.—The various encephaloid masses scattered through- out the brain, consisted of a vascular stroma, and a thick creamy juice. A drop of the latter contained numerous cancer cells in all stages of development, as repre- sented Fig. 277, p. 215. The stroma of the small masses consisted of a plexus of vessels of various sizes, crossing and inosculating with one another, many forming loops which were enlarged and crowded with blood corpuscles as in Fig. 151. In the CANCER OF THE BRAIN. 423 larger masses the vessels had undergone development, by pushing out from their sides prolongations, which, subsequently uniting, formed a plexus (as seen in Fig. 302). . During this process, however, another change had occurred, viz., an in- vestment of these prolongations, which often assumed the form of acini in a gland, with a distinct membrane, in the interior of which was a vascular loop. It re- sulted that whilst some part of these masses contained a vascular plexus, with numerous cancer cells in a mesh-work, in others it exhibited a structure, now Fig. 412. Fig. 413. villous, and now approaching towards that of a gland (Figs. 392, 393). This was evidently the " Cancer Stromata," so well described by Rokitanski, in some forms of encephaloma. The small cancerous nodule in the spinal cord presented the same structure as those in the brain. For the most part the nervous substance surround- ing these masses was quite healthy; but here and there, in their immediate neighbor- hood, it contained a few granule cells. The cancer of the lungs and bones presented the usual structure of encephaloma in those organs. Commentary.—The occurrence of cancer in the brain is exceedingly rare; and the form of it above described was seen by me for the first time, and examined with the greatest care. Its structure histologically was very interesting, and contrasted in some remarkable particulars with another well-observed case recorded by Dr. Redfern of Aberdeen,* in which the stroma consisted wholly of shreds of cell membranes and granules. Before death, there were manifested both a cerebral and spinal disease. The former occasioned a peculiar perversion of the mind, consisting of a certain confusion of thought and incapability of carrying on ideas, whilst he answered questions readily and appeared perfectly conscious. Theoretically this is readily explained by the numerous circumscribed cancerous masses which may easily be supposed to have disturbed that continuity of transmission along the tubes so essential to vigor of mind. The spinal disease was indicated by local pain and incapability of supporting himself erect, symptoms attributable * Monthly Journal of Medical Science, December 1850. Fig. 412. Peculiar vascular stroma with villi in the larger cancerous masses of the brain, acetic acid being added. The interstices were crowded with cancer cells. Fig. 413. Gland-like expansions of stroma in other portions of the same mass. 80 di. 424 DISEASES OF THE NERVOUS SYSTEM. to the osseous disease and weakness. The paralysis of the right lower extremity may be owing to the nodule of cancer in the spinal cord opposite the dorsal vertebrae; but this is by no means certain. There was some difficulty in determining whether the indisposition to walk and powerlessness was owing to atrophy of the limbs or to a true paralysis. I am disposed to think that both causes co-operated. DROPSY OF THE BRAIN. Case XXXI.*— Chronic Hydrocephalus—Paracentesis Capitis—No Benefit. History.—Esther Little, set. 17 months, was admitted June 27, 1857. Her birth was natural, and nothing peculiar in the size or shape of her head was then ob- served. For two months her health was perfect; she then had convulsions, vomit- ing, and strabismus; her appetite diminished; her abdomen swelled, and there were frequent green slimy stools. She was under medical treatment for nine weeks, when she began to improve, and from that time her mother has noticed no deficiency in her appetite. When five months old a swelling appeared on left side of neck; it was lanced, and soon afterwards healed. But about this time also—twelve months ago—the size of the head attracted the attention of her parents; and from that day, up to admission, it has been gradually increasing. The child is thought by her parents to feel no pain in her head, but only inconvenience from its weight. She has not suffered from dentition, and has now cut ten teeth. She has not yet been weaned. Symptoms on Admission.—The child is not emaciated, the arms, legs, and body being well nourished; it often smiles, but the smile is readily converted into a querulous cry. It is fretful on the slightest change in the position of its head, which is too heavy for it to support. The head is of an irregularly square shape, the left side appearing to bulge posteriorly a little more than the right. The anterior fontanelle, 4 inches broad, and 9 inches at its greatest length, gives a distinct sense of fluctuation, being at the same time tense. The veins are seen with unusual distinctness coursing over the head. There are laminated scabs of chronic eczema over the scalp. The forehead is projecting. The eyes appear to Fig. 414. Fig. 415. Fig. 416. protrude against the inferior eyelids, which cover the greater part of their sur- face. The upper lids are retracted slightly, and leave the sclerotic exposed. The lids are somewhat red. There is no strabismus; there is intolerance of strong * Reported by Mr. W. Guy, Clinical Clerk. Figs. 414 to 416. Lateral, vertical, and front views of the head of Esther Little. In consequence of the well-nourished face and limbs, the drawing does not convey to others an idea of the comparative size of the head so well as usually occurs in these cases. DROPSY OF THE BRAIN. 425 light. The features of the face are well-proportioned, and the cheeks bear a good deal of color. The measurements of the head were found to be 24 inches at the greatest circumference (the girth on the left side being 12£), 15 inches across the head from ear to ear, and 16 inches from the frontal sinus to the occipital pro- tuberance. On examination, the cardiac sounds are healthy, and the respiratory murmurs are natural. The tongue is moist and clean. The appetite is reported good. The child is not yet weaned, and is often at the breast; it, however, also gets milk, beef-tea, and bread. Its bowels are reported to be regular. The urine is passed in good quantity, but none has been obtained fpr examination. The mother has five living healthy children. . Progress of the Case.—The hair being clipped close, the tincture, of iodine had been painted over the scalp. July 6th.—To-day, about 1 p.m., tapping was performed by Mr. Syme. A small trochar being introduced to the depth of about one inch behind the posterior edge of the right os frontis, one inch to the right of the mesial line, five ounces of fluid were withdrawn. A compress was then applied over the puncture and secured by strapping. Slips of diachylon plaster were also applied from side to side and obliquely, to effect gentle compression, and support was further given by a bandage passed round and across the head. There was very little crying on the part of the child. The fluid was clear as water; alkaline; sp. gr. 1009; depositing slowly, after being heated and acidified, a slight amount of albumen, and giving also (under action of sol. sulph. cupri, aqua potassa? and heat) a trace of grape sugar. July 12th.—Since the operation there have been no symp- toms of nervous excitement or derangement. On measurement of head to-day, was found to be the same size as on admission. July 14th.—Yesterday, on again measuring the head, the same results were obtained. To-day, Mr. Syme again per- formed paracentesis, removing twelve ounces, the puncture being made on the left side at a point corresponding to the previous one on the right: the fluid exactly resembled that formerly drawn, but did not give the grape-sugar re-action. The head was gently compressed while the fluid was flowing through the tube, and until, by means of strapping and bandage, equable pressure was applied to the cranium. The scalp was collapsed and puckered after the operation, and the bony margins of the fontanelle had considerably approached one another. July 16th.— Child has been more fretful; has passed less water: ordered ten drops of sp. ether nilrici thrice a day. July 11th.—The urine has increased in amount. The child has recovered its usual health. July 21st.—To-day, the seventh since the operation, the bandages were removed; the coronal region felt full, and on measurement, the same numbers were obtained. July 24th.—Paracentesis was again performed; twelve ounces were removed, the fluid being faintly yellow; 1008 sp. gr., and otherwise identical in character with the fluid formerly withdrawn. At close of the opera- tion rigors occurred, and the child looked pallid and faint. It was revived by wine and warmth; it partially vomited the wine; it was then kept at the breast, and by the evening it had regained its usual aspect. July 25th.—The urine again scanty; slept well last night; is exceedingly fretful, and does not incline to the breast. July 26th.—The fontanelle is again tense; urine still scanty; did not sleep well last night. July 21th.—Slept better; urine slightly increased, but none can be obtained for examination. July 28th.—Again slept better; appetite is returning; the child is very fretful; but otherwise has no unusual symptom. The mother is anxious to return home, and a fourth paracentesis is not deemed advisable. The head was again measured, and found to be of the very same size as on admission. Discharged, July 28th, 1857. Chemical Examination by Mr. Turner of the fluid removed. The fluid was especially examined with reference to the question whether it pos- sessed the power of deoxidising the blue hydrated oxide of copper like grape-sugar. This property was possessed by the first specimen, the reduction to the state of sub- oxide taking place after boiling for a few minutes. No such re-action could, however, be obtained from the second portion, although the experiment was tried several times, both with the fluid as received, and also with it after it had been considerably concentrated by evaporation. The third specimen, however, exhibited the re-action in a more decided manner than the first. All three specimens contained albumen in small quantity. Heat and nitric acid causing it to fall down as a white flocculent precipitate. The following inorganic constituents were also found in the fluid in minute quantities:—Chloride of sodium, phosphoric acid, lime and magnesia. 426 DISEASES OF THE NERVOUS SYSTEM. Commentary.—The history of this case indicates that, two months after birth, the child had probably an attack of acute meningitis at the base, from which she recovered. From this period dates the commence- ment of the hydrocephalus, a circumstance which induced me to suppose that the chronic exudation had in some manner compressed the blood- vessels, and caused dropsy. I have previously pointed out that such is the pathology of effusion following acute meningitis (p. 372), and there is every reason to suppose, that such is the explanation of the slow accumulation of fluid in the present case. With the exception of the cerebral disease, there was no other malady. So far as I could discover, there was especially no tubercular complication, which is generally so much to be dreaded in these cases, and all the functions were performed naturally. On the other hand, the mother assured me that the head was daily enlarging, and it was clear that, under no circumstances, if left to nature, would the child's existence be an enviable one. Under these circumstances I determined to try the effect of cautiously removing the fluid, and seeing whether the cause producing the effusion might not have ceased to operate, when assisted by diminished pressure. The first five ounces of fluid removed, produced no disturbance in the child what- ever, and, encouraged by this circumstance, on the next occasion twelve ounces were taken away. On this occasion the head was greatly diminished, and the scalp considerably corrugated immediately after the operation. The head subsequently was carefully covered with strips of adhesive plaster in the manner recommended by Mr. Barnard, and the whole supported by bandaging. For a few days afterwards, the child exhibited somewhat more restlessness, soon followed by a little unusual stupor. This I attributed to a re-accumulation of the fluid. On re- moving the bandages the head was found to be of the same size as on admission. Subsequently the scalp became very tense, and another twelve ounces were removed, followed by bandaging. On this occasion, however, the operation was followed by a rigor, but the child speedily recovered. The mother next day informed me that on this, as on the preceding occasion, the urine was diminished, although I had endeav- ored to meet the possibility of this occurrence by the exhibition of nitric ether. This circumstance, therefore, convinced me that no benefit was to be anticipated from continuing the tappings, and the mother and i child consequently returned home. I have since heard from Dr. Anderson of Selkirk, that, a few days after returning to that town, the child died, but as he was unfortunately absent at the time, he did not see her, and she was buried before his return. From an account fur- nished by the parents of the symptoms which preceded death, it appears that there was no vomiting, unusual restlessness, strabismus, convulsions, paralysis, nor coma. But there was great pallor, disinclination to take food, and exhaustion. Had she remained in the Infirmary, these symp- toms, and the fatal results, might have been delayed by the judicious administration of nutrients and stimulants. The most satisfactory proof of the occasional benefit of tapping the head in cases of chronic hydrocephalus, is to be found in the paper of Dr. Conquest,* who at that time had operated in nineteen cases, and in ten of these successfully. He tells us that "all the operations were * Lancet, vol. i. 1837-38, p. 890. STRUCTURAL DISEASES OF THE SPINAL CORD. 427 performed in the presence of many medical gentlemen, and most of them before large bodies of students at St. Bartholomew's Hospital." One of these cases, that of Catherine Seager, in its general details was very like the one now under observation. Two pints of fluid were removed by the operation, followed by a convulsion. Yet she was seen by Dr. Conquest, two years and a half afterwards, perfectly well, and in complete possession of all her intellectual faculties. With such facts before us, it is clear that the operation is warrantable when, from an absence of complication, there is a reasonable hope of success, as existed in the present case. Should another case present itself to me, I would allow a longer time to elapse between the tappings. With this exception, I do not know, on a retrospective view of all the circumstances, that there was any point in its treatment that required modification. It would be a matter of great practical importance to determine, whether, as a rule, evacuations of the fluid are as useful in advancing as in stationary cases of chronic hydrocephalus. It is probable that the good effects described by Dr. Conquest were obtained in the latter kind of cases. STRUCTURAL DISEASES OF THE SPINAL CORD. Case XXXII.— Otorrhea—Sudden Lumbar and Cervical Pains—Convul- sions—Spinal Meningitis. History.—Martha Bell, aet. 19, servant—admitted on the evening of May 29th, 1863. She has since childhood suffered from otorrhoea and occasional pains in the right ear, but in all other respects has been healthy. After her last menstruation, wkich terminated on the 21st, the ear became more painful than usual, and there was an increased discharge from it. The symptoms were followed by languor and disinclination for work. On the morning of the 24th there was nausea, and in the evening vomiting. During the next two days the vomiting returned frequently at irregular intervals, the matters rendered being tinged with bile. On the 27th she experienced severe pains in the neck and in the lumbar region, and in the evening there was a rigor followed by febrile symptoms, which have continued since. Symptoms.—May 30th.—There is no headache, but she complains of severe pain in the back of the neck and across the lumbar region, which is not increased on pres- sure. Intelligence, sensation, and motion normal; the tongue is slightly furred ; no pain or swelling; no appetite, great thirst; severe nausea ; slight abdominal tenderness; constipation, the bowels not having been relieved since the 24th; pulse 120, of mode- rate strength; respiration hurried; urine loaded with urates ; a purulent fluid flows from the right ear, unaccompanied by pain even on pressure; skin hot and dry; a warm poultice to be applied to the right ear and a domestic enema to be administered. May 31st.—Passed a restless night. There has been no recurrence of vomiting although she has taken food tolerably well. There is still, however, nausea, with frequent ex- pectoration of saliva; pulse 120, weak,; bowels not relieved; great pains and rigidity in the muscles of the neck. To have § j of 01. Ricini. June 1st.—Last night her agony was so great that a draught was ordered containing M. xv. of Sol. Mur. Morph. and of Chlorodyne. At midnight, though quite sensible, she became very restless, frequently endeavoring to get out of bed. During the previous afternoon the pain in the side and back had considerably increased. During the night the bowels were opened twice but without giving her relief. On both occasions she rose from bed to go to stool. Towards morning the patient became more quiet, but took h&r breakfast readily. At the visit she was found insensible, lying on the back, head resting on left side, both arms twitching convulsively, with slight interrupted moaning. Skin hot and covered with perspiration. Pulse 160, small and weak. No rigidity of muscles of neck. About half past one p.m. a loud mucous rattle was heard in the throat. Dyspnoea came on, and she died at hah" past two p.m. Sectio Cadaveris.—Twenty-four hours after death. The body was well nourished. 428 DISEASES OF THE NERVOUS SYSTEM. Head and Spinal Cord.—The cerebral membranes were congested. Their surface was somewhat dry. At the base of the cranium there was an abundant formation of pus between the arachnoid and pia mater, reaching as far forwards as the optic nerves and backwards over the pons and medulla oblongata. It extended to the lower end of the cord, but existed only posteriorly as far down as the third dorsal vertebra. Below that point it surrounded the whole organ, and was more dense. There was no change to be observed in the substance of the brain or the cord. Other organs normal. Commentary.—This was a characteristic case of acute spinal menin- gitis, in which both the cranial and vertebral portions of the cord were affected. It will be observed, that with fever there was no headache, but considerable nausea and vomiting, pain and stiffness in the neck, , which extended to the back. The pain in the latter situation became intolerable, without paralysis or any symptom of myelitis. Lastly, con- vulsions and death. The fatality of this formidable affection is in pro- portion to the amount of the cord involved. Its treatment should consist in rest, supporting the strength to enable the pus to be absorbed, and applying local warmth to relieve pain. In the early stage, local cold or the application of ice may be supposed to be effective, but then the symp- toms so closely resemble those of acute rheumatism, that the disease is seldom detected. Case XXXIIL*—Acute Myelitis in the Cervical portion of the Cord— General pains resembling those of Rheumatism—Fugitive Paralysis in the arms and legs—Engorgement of the Lungs—Death. History.—Duncan M'Lean, set. 27, a laborer, married—admitted November 1st, 1858. Patient states that on the 19th October he was driving cattle, and got wet through. Having been engaged all that night, he did not change his wet clothes, hut drunk a good deal of whisky. On the following day he went into a railway carriage while perspiring profusely, fell asleep, and felt cold and stiff when he awoke. He went home, changed his clothes, and remained well until the morning of the 26th, when he experienced pain in the calves of the legs as he walked to his work. This became more severe during the week, and extended upwards to the muscles of the thigh, and thence to the intercostals, and to the muscles of the shoulder, arm, and lower jaw. When he sat or stood at rest, the pain was scarcely felt, but it was excruciating during motion or when firm pressure was made on the affected muscles. On the 30th October, when standing in the street—the evening being cold—the pain became exceedingly severe, so as to compel him to return home. He had at that time also a sensation of stiffness over the body. He remained in this state till November 1st, when as he was coming down stairs on his way to the Infirmary, bis strength failed him, end he had to be conveyed in a cab. Symptoms on Admission.—Pulse 70, of good strength. Respiration noimal. Has a slight cough. Complains of pain in almost all the muscles of the body, and this is greatly aggravated by pressure or movement. Bending the joints only causes rain in the muscles. He cannot put his tongue far out on account of the pain en opening his jaw. It is slightly furred, dark in the centre, and trembles constantly. Complains of great pain at the back of his throat in the act of deglutition. Appetite almost gone; considerable thirst; bowels costive. Urine strongly acid—otherwise normal. The skin feels rather warmer than natural, and he sweats much at night. He teas ordered half drachm doses of bicarbonate of potash thrice daily, dissolved in four ounces of water. Progress op the Case.—November 4th.—The pains still continue as severe as ever. Otherwise much in the same state as when he entered the house. R Spt. jEth. Nitrid 3 ij ; Aq. Acet. Ammon. 3 ij ; Aquce ad % iv, ft. mist. A tablespoonful to be taken every four hours. Nov. 6th.—He speaks thick, as if his tongue were paralysed. Has scarcely slept since he came into the hospital. Unable to move his hands or feet. He cannot shut his eyes fully, the left being uncovered when he tries to do so, to the * Reported by Mr. T. S. Clouston, Clinical Clerk. STRUCTURAL DISEASES OF THE SPINAL CORD. 429 extent of one-eighth of an inch, and the eyes are suffused and lachrymating. He has great thirst, and chewing and swallowing are performed with difficulty. Has had reten- tion of urine for two days, and required the use of a catheter. Retention has now ceased. He passed his stools in bed to-day when in a dozing state. November 1th—Counte- nance anxious and depressed; eyes suffused; pulse 120. Cannot move right arm or either leg. He has the sensation of pricking with pins and needles in the feet, but no pain in any part of the spine, except at the back of the neck. Great pain in the temporal region. Ordered to be cupped to the extent of five ounces over the back of the neck, the glasses to be applied along the middle line. R Tinct. Hyoscyam. m. x. Aqua § j; ft. haustus, hora somni sumendus. Nov. 8lh.—Passed a restless night. Three glasses were applied, but only half an ounce of blood extracted. He is not in the least relieved. Complains to-day of a constriction round his chest, a little below the level of the nipples. Eyes no longer suffused, and he can move his right arm readily, but not his legs. Tongue coated with a dirty fur, pulse 110. Sweats a great deal and the perspiration has a peculiar mousy odor. Bowels freely moved by cas- tor oil. Ordered again to be cupped over nape of neck to five ounces. Nov. 9th.—The amount of blood ordered was drawn by cupping without producing any relief. Com- plains of great pain in his hands and feet, which had kept him awake during the night. The right arm is again paralysed, and he cannot lift it from his chest. The left arm is now in the same condition. R Pulv. Ipecac. Comp. gr. x. To be taken at bed-time, and that failing to induce sleep, to have 25 minims of Sol. Mur. Morph. Nov. 10th.— No change. He slept for two hours after getting the morphia. R Sp. uEth. Nitrici 3 ij ; Potass. Carb. 3 ij ; Tinct. Gent. Co. § vi; Infus. Gent. Co. § v; ft. IFist. Two table-spoonfuls to betaken thrice daily. Nov. 11th.—Feels the sense of constriction as if tied with a cord round the chest. He has a cough, but cannot expectorate easily on account of the constriction. Nov. 12th.—Cannot cough up the rather viscid ex- pectoration, which produces a gurgling in his throat. There is some harshness of inspiration. He can move his arms better than yesterday, and the left more than the right. The sensibility of the soles of his feet is much diminished, but is more acute in the right than in the left. Skin is hot; perspiration copious. Urine is alkaline to-day, and throws down a copious deposit of phosphates. Ordered three ounces of wins daily and 3 ss of Sol. Mur. Morph. at night. Nov. 13th.—Slept very little on account of the pain hi his legs, toes, and heels. Pulse 130, rather weak. Feeling of constriction not quite so troublesome to-day as yesterday. Appetite quite gone. Hot fomentations to be applied to the feet and lower part of the leg, which failing to give relief, they are to be painted over with the tinct. of aconite. Nov. 14th.—He became much worse last night, and to-day his face is pale and expressive of great suffering; eyes sunk, and he can scarcely speak. Respiration very quick and diffi- cult, and he h constantly pointing to his breast as the seat of pain. Loud mucous rattle in the throat; marked dulness all over right side anteriorly; feeble respiration and mucous rattle all over this side. Harsh respiration and very coarse mucous rattle all over left side. He expectorates pure pus. He can move his arms more freely than yesterday, and now also his legs to a limited extent. A tablespoonful of wine every two hours. Vespere.—Skin covered with an exceedingly profuse perspira- tion ; respiration still more difficult than during the day; pulse quick and feeble; almost imperceptible. Abdomen very much distended with gas, impeding still more the labored respiration. Ordered a foetid enema. Nov. 15th.—Has rallied consider- ably to-day. Respiration much easier; abdomen less distended; pulse 126, and much stronger; expectoration purulent and copious. His power of moving the legs is greater than yesterday, but still very limited. Crack-pot sound, and a great in- crease of vocal resonance over the whole chest anteriorly. On account of the pain the attempt gave him, and his weakness, his lungs could not be examined posteriorly. Urine has again an acid reaction; chlorides much diminished. Nov. 16th. Yester- day evening he vomited about three ounces of a thin yellowish-green fluid. Sense of constriction of chest still remains, and the same mucous rales, etc., as formerly m2ntioned. Pulse 120, irregular. Complains ,of a burning in his throat; tongue covered with a dirty-greyish fur, and livid at the tip ; feels slight nausea; can take no solid food, but only wine and beef-tea. Sleep is very much disturbed by pain and a sensation of pricking in his heels and ankle-joints, and this is but little relieved by the warm opiate fomentations applied over those parts. Nov. 11th.—Pain in his heels not relieved by aconite or warm fomentations with opium. It distresses him exceed- ingly. Nov. 18th. Voluntary motion in his arms is now almost as perfect as in a healthy individual, but is limited in the legs. Pulse 130, small; sputum very copious 430 DISEASES OF THE NERVOUS SYSTEM. and purulent. Nov. 19th.—He has a depressed and pallid look, and is very restless. Lips and tongue livid; pulse 126, weaker than yesterday. Mucous rattle heard all over the chest anteriorly ; respiration heaving and quick ; expectoration diminished. Died at half-past 3 p.m. > Sectio Cadaveris.—Forty-seven hours after death. Head.—Membranes of brain rather drier than usual, but nothing abnormal could be detected in the brain or its nerves. Spinal Cord.—Membranes healthy, but on slitting up the cord, its substance was found to be slightly softened in a space about an inch in length, at the level of the third and fourth dorsal vertebras. The diseased portion of the cord presented its healthy appearance to the naked eye, but the softening, though apparent to the touch, was rendered evident by the flocculent surface produced on subjecting the section to a slender stream of water. Thorax.—The right lung was found to be strongly adherent to the thoracic wall, and there were many puckerings at its apex. The anterior edges of both lungs were emphysematous, and on section, were found to be of a prune juice color, congested and dense in patches, the parts between being still crepitant. This condition was most marked at the base of both lungs, especially that of the right. The bronchi contained a large quantity of pus, the mucous membrane being congested, and of a mahogany color. On squeezing a portion of the lung-substance, bloody and purulent matter was pressed out. All the other organs were healthy. Microscopic Examination.—The softened portion of the cord contained some granular exudation with a few granule cells. Several demonstrations were made from other parts of the cord, but nothing abnormal was found in them. Commentary.—Cases of acute myelitis are rare, and are almost uniformly fatal. In the present instance the symptoms commenced with the usual signs of fever and of general muscular rheumatism, followed by retention of urine and difficulty of deglutition. The insomnolence and haggard expression of countenance led us to fear that the brain might be implicated; but the total absence of mental confusion, the local pain and the appearance of paralysis in the arms, at once indicated the cervical portion of the cord as the seat of the disease. The fugitive character of the paralysis was remarkable, at first appearing in the right arm and leg; on the following day disappearing in the arms, then once more returning, and again towards the close of the case, altogether disappearing from the limbs. This must have been dependent on the congestion, which was more intense at one time than another, and which preceded the exudation. The sense of constriction round the chest was harassing, and latterly the lungs became engorged, one of the most common complications preceding death in cases of myelitis at the upper part of the cord. The treatment was on his admission directed to combat the supposed rheumatism, at first with alkaline salts, and secondly with Dover's powders. As soon as the spinal character of the disease was manifested, anodynes were freely given with cupping over the seat of pain in the neck as a palliative. But it is to be ob- served that none of these remedies, whether internal or external, gave him the slightest relief. The disease took its relentless course, and life was only prolonged by assiduous efforts to -support the system by nutri- ents and by wine. Case XXXIV.*—Slight Paraplegia.—Recoverg. History.—William Macpherson, set. 33, a blacksmith, a very muscular and appa- rently strong man—admitted June 1, 1853. For two months past he has suffered from pain between the shoulders, in the legs, and over the body generally, and during the last three weeks he has been very weak, frequently feeling as if the arms and legs * Reported by Mr. "William Calder, Clinical Clerk. STRUCTURAL DISEASES OF THE SPINAL CORD. 431 were benumbed. He has been an intemperate man, but never had delirium tremens, paralysis, or other disease of the nervous system. Symptoms on Admission.—There is no tenderness on percussion along the spinal column, and he only complains of pain between the scapulas, shooting into both shoulders, increased by coughing and by motion. He says that both arms are very weak and benumbed, and that they often tingle, especially when he coughs. The arms are muscular, but the grasp he takes of an object is feeble, while the sensibility of the skin is decidedly diminished. Both arms are similarly affected. The legs also are very weak, more especially the left one, which " shakes" when he walks, especially if going down a hill. During progression the gate is unsteady, the left leg beino- jerked outwards in a semi-circle. He cannot turn round rapidly, and has slight difficulty in standing with the eyes shut. The sensibility of the skin over the inferior extremities as well as over the abdomen and thorax, is diminished to the same degree as in his arms. Occasionally there are involuntary startings of the legs and arms, especially at night, which sometimes prevent his sleeping. In all other respects the functions are normal. Appetite excellent. No constipation. R 01. Ohvar. J ss; 01 Crotonis 3 ij. M. ft. linimentum et inter scapulas apphcetur. R Hydrarg Proto- iod. gr. vj; Ext. Hyoscyam.: Ext. Aloes, aa 3j, M. et Jiantpil. xij. Sumat unam ter Progress of the Case.—June 6th.— Thinks himself somewhat better. Complains that his diet is insufficient. To have lib of beef-tea in addition to ordinary diet. From this time he gradually recovered, and was dismissed on the 17th, still a little weak, with the perfect use of all his limbs, and the sensibility normal. Case XXXV.*—Paraplegia—Partial Recovery. History.—Benjamin Robertson, set. 42, a tailor—admitted July 11,1853. States that he enjoyed excellent health, until between three and four months ago, when he began to experienoe a constant feeling of coldness in both feet accompanied with a certain amount of numbnes3. The diminution of sensibility gradually extended up both limbs, and in the course of six weeks they were wholly affected. Together with the numbness, the power of walking became impaired. This he attributes partly to want of muscular strength, and partly to the feeling of insecurity caused by the loss of sensibility. After the lower limb3 had become involved, the fingers of both hands became similarly affected. Occasionally he has felt as if a belt were firmly bound round the loins and lower part of the chest. He has never had pain in the back, or tenderness on percussion along the spine. For the last ten years his habits have been temperate, but previously he was much addicted to intoxication and venereal excesses. The treatment hitherto has consisted of counter-irritation over the back, and inter- nally iodide of potassium. Symptoms on Admission.—Has no pain anywhere, but sensibility is diminished in both lower extremities, and more especially in the feet. His power of movement in the ankle joints and toes is unimpaired, but he has less command over the knee and hip joints. He is unable to draw up the limbs in bed beyond a certain point, but the left leg seems to be a little stronger than the other. He has no involuntary startings of the limbs, but he has observed that they move about irregularly when friction is applied to them. He has great difficulty in walking, feeling as if his knee joints would bend under him, and before advancing he requires to steady himself on one foot for a little. On shutting his eyes he falls forward immediately. The fingers are con- stantly benumbed, but he can move them perfectly. Arms unaffected. With the exception of defalcation, all the functions are normal; but on feeling an inclination to evacuate the bowels, he is obliged to comply instantly, or the faeces would pass invol- untarily. I£ Strychnia! gr. j ; Ext. Gent. 3 ss. Mica; Panis. q. s. ft. massa in pil. xij. dividenda. Sumat unam ter indies. Progress of the Case.—The pills in the course of eight days produced involun- tary startings of the inferior extremities, but the symptoms otherwise remained the same. R 01. Olivar ; 01. Crotonis, aa ^ ss. To be rubbed over the lower half of the spine morning and night. July 28th.—His general health remains good, and he thinks there is some amendment, although none is very perceptible. From this time, repose, good diet, and occasional counter-irritation, constituted the only treatment, under which he gradually improved, so that November 1st, when he was dismissed, he was able to walk iconsiderable distances with the aid of sticks, and a Uttle even without them, although unsteadily. * Reported by Mr. Alexander Struthers, Clinical Clerk. 432 DISEASES OF THE NERVOUS SYSTEM. Case XXXVI.*—Paraplegia—Incurable. History.—Maximilian Saulsen, set. 35, perfumer, native of Warsaw—admitted January 9, 1851. States that two and a half years ago he first felt a pricking, fol- lowed by numbness in the toes of his right foot, which gradually extended, being accompanied by diminution of voluntary power over the parts. His left leg then became similarly affected. His general health was good. In 1849 he went to Germany, where he made use of the baths of Weisbaden. Returning to England he applied to one of the London dispensaries, and here he was cupped and galvanised without benefit. During last summer he went again to Germany. He says he could not walk on board at this time; but when he left for England in October last he was obliged to be lifted on board, his legs being useless, while his arms were unaffected. • During the passage back from Hamburg, two months ago, his left hand felt benumbed and he could with difficulty use the fingers, except the little finger, which he says was unaffected. The right hand remained natural, with the exception of the little finger which felt numb. Since then, the numbness in the feet and inability to move have increased very much. Symptoms on Admission.—On admission his general appearance is healthy. He is unable to walk to any distance without the assistance of a stick. He is unable to direct the motions of his right leg without watching it. When he stands without support, great unsteadiness is observed ; and when directed to close his eyes, he loses all control over his movements, and would fall to the ground if not prevented. He is unable to use the fingers of the left hand with any precision. Sensibility of the skin unimpaired. No headache ; no tinnitus aurium; a little dizziness occasionally. Urine passed without difficulty ; sometimes involuntarily during the night—1023 sp. gr. Complains of difficulty of defalcation. He was ordered to be cupped and blistered. These remedies in conjunction with repose in the Infirmary, produced considerable amendment, and he was enabled to take long walks with the aid of ii stick. On Friday the 10th, he passed a large lumbricus; and 40 grains of Fulv. Red. Filicis Maris were ordered to be taken night and morning. No more woims, however, were evacuated. On February 23d, he was ordered one-twelfth of a grain of strych- nine twice a day, which dose was increased to one-sixth on the 28th. On the 1st and 2d of March, he was awakened several times during the night by startings of the limbs; and he stated that their general strength was diminished. He evidently stag- gered more in walking. Galvanic currents were then ordered to be passed from the spine down both limbs, under which treatment he continued until the 31st of March, when, being in no way better, he was discharged as incurable. Case XXXVII.f—Paraplegia—Chronic Myelitis. niSTORY.— James Roy, set. 34, a tailor—admitted September 20, 1847. States that about three months ago, he first observed slight unsteadiness in his gait, with a feeling of coldness in his lower limbs, which gradually increased. About a month afterwards, he became unusually constipated, with a want of power of expelling the faeces and urine. On the 15th, feeling unwell, though he had worked all day, he retired to rest earlier than usual, but, feeling uncomfortable, he got up and found he had little power in his legs. About twelve o'clock that night they became completely insensible. Next morning he had lost the functions of defalcation and micturition. A medical man bled him largely, removed the urine by catheter, and administered purgatives, which opened the bowels. He has remained in the same situation since, always feeling great faintness on assuming the erect posture. Symptoms on Admission.—All the parts below a line drawn round the body on a line with the nipples appear to be perfectly paralysed, deprived of all motility and sensibility. The inferior extremities present no rigidity whatever. Only the upper half of the chest moves during respiration; the lower half and the abdomen being fixed. There is retention of urine, which requires to be drawn off by catheter; and his bowels, which are very costive, are opened involuntarily in bed. Has a feeling of constriction round the chest, and still feels faint on being placed in the erect position. Temperature of the body everywhere natural. Pulse 90, of good strength. Other functions normal. Progress of the Case.—The symptoms underwent no change, but he gradually became weaker. The treatment consisted at first of cupping over the vertebrae, and * Reported by Mr. Sanderson, Clinical Clerk. f Reported by Mr. James Struthers, Clinical Cierk. STRUCTURAL DISEASES OF THE SPINAL CORD. 433 purgatives, and subsequently of the iodide of potassium internally, and wine. Octo- ber 12th. Diarrhoea came on yesterday, and he died this morning. Sectio Cadaveris.—Twenty-five hours after death. Spinal Cord.—Permission could only be obtained for the examination of this organ, which was exposed from the first cervical vertebra downwards. The mem- branes were healthy. Scarcely any arachnoid fluid. About seven inches of the cord in length, corresponding to the second and third dorsal vertebrae, felt unusually soft. Externally the softening was of a dirty gray color, and pultaceous in con- sistence, but the centre was quite diffluent, and of a yellow color, resembling pus. Above and below the circumscribed morbid portion the cord was healthy. No dis- ease of vertebrae. Microscopic Examination.—The external gray softening consisted of fragments of the nerve tubes, and globules, with double lines of various sizes and forms, mingled with numerous granule cells and granules. The central softening consisted almost wholly of numerous granule cells and fatty molecules, fragments of tubes being com- paratively small in quantity. Commentary.—The four preceding cases present the same disease in different stages, that disease being chronic myelitis, by far the most common lesion of the cord met with. Cases XXXIV. and XXXV. show the occasional good effects which result from rest, counter-irrita- tion, and supporting the nutrition in incipient cases. Bleeding and anti- phlogistics I have never seen beneficial, but frequently injurious; and in Case XXXVII. depletion evidently added to the prostration of the patient. In the more chronic or intense cases, nothing but palliatives are of any service. I have tried galvanism and strychnine, but have never found them of any avail where the cord was undoubtedly diseased. Indeed, under such circumstances, it has frequently appeared to me that strychnine renders the weakness of the patient greater, as in Case XXXVI. In the last stages of the disease, if chronic, and especially if sloughs have formed on the back, our whole efforts should be directed to nurse and sustain the patient's strength, and alleviate the symptoms which arise from the paralysed condition of important organs. Hence rest, nourishing diet, and tonics, are the best remedies, while the hydro- static bed and every other contrivance should be put in practice to remove pressure from the depending parts of the body. Mild aperients should be employed from time to time to overcome the intestinal torpor, while by the catheter the urinary bladder should be evacuated, so as to diminish the tendency to saline precipitation in that viscus, and its sub- sequent disorganization. I have given phosphorus in seven cases of paraplegia from ehronic myelitis, all resembling more or less Case XXXVI., in the form of phosphuretted oil (4 gr. of phosphorus dissolved in § j of olive oil). In none of these cases have I been able to satisfy myself that any im- provement was occasioned. I commenced with three drops a day, which were afterwards cautiously increased to ten, and in one case to fifteen drops. But these large doses soon induced violent nausea and vomiting, and after a short suspension of the remedy, I have continued it for several weeks in doses of three drops. In the case which took fifteen drops thrice daily for two days, the phosphorus was excreted by the lungs, as the breath smelt strongly of the drug, but was not phosphor- escent at night—a phenomenon which has been seen by some physicians who have employed it. In another case, that took ten drops thrice one day, a large amount of phosphate was passed in the urine* presenting, 434 DISEASES OF THE NERVOUS SYSTEM. under the microscope, beautiful feathery crystals, which disappeared on discontinuing the drug. From the trial I made of phosphorus, it seemed to me of little benefit, and that the dose of phosphuretted oil should never exceed five drops. Even this amount cannot be adminis- tered for any length of time without deranging the stomach. In the spring of 1859, I treated six cases of paraplegia with ergot of rye, 5 gr. three times a day. They were all watched with great care, and in three of them considerable amendment took place. At the time the trial of the drug was considered favorable. All three cases, how- ever, it was ascertained after dismissal, again became worse. Since then I have given the drug in the same manner to thirteen other cases of paraplegia—increasing the dose to ten grains—and although there has been temporary relief in some of them, it has always appeared to me attributable to the rest and good nourishment of the hospital. In a few of these cases the ergot was taken two months without intermission, and in two for three months, not only without symptoms of poisoning, but without any inconvenience whatever. The cord undergoes the same structural changes as the brain, and after death, in cases of true myelitis, exudative softening may readily be demonstrated by the microscope. (See Fig. 401.) Softening from im- bibition of serum, however, is rare, whilst that from mechanical crushing with instruments after death is exceedingly common, and should always be carefully investigated by the pathologist. Spinal meningitis and hemorrhage are rare diseases—the former generally resulting from an extension downwards of cerebral meningitis. (See Case XXXII.) I have only seen one case of spinal hemorrhage, and that occurred in the surgical ward of Mr. Miller. It occurred in a woman, who, when tipsy, was kicked by her husband in the neck, with the immediate result of paralysis of all four extremities, and of the trunk. She died in four days, and, opening the body, I found a clot of blood the size of a pea in the centre of the cord immediately below the medulla oblongata, opposite the second vertebra. The external portion of the cord, and the vertebral bones, were unaffected. On microscopicexamination, the clot was com- posed of recently extravasated blood corpuscles, surrounded by mechanical softening.* Case XXXVIII.f—Paraplegia—Tubercular Caries of Dorsal Vertebra— Myelitis—Pidmonary Tubercle. History.—William Walker, set. 42, mason—admitted October 17, 1850. States that for upwards of twelve years he has suffered from occasional cough, usually dry, accompanied in lower and middle part of chest with pain, extending back to the dorsal vertebras. The pain and cough have, within the last three months, become more constant, and are accompanied by nightly perspirations. About fourteen days before admission, he felt a prickling and coldness in the feet, and an unsteadiness in walking, especially with the left foot. Two days before admission, after a long walk, these symptoms were augmented. Since then they have gradually increased, so that now he has no power over his legs beyond bending the knee very slightly. Sensibility of the integuments not impaired. Symptoms on Admission.—On admission, looks emaciated and anxious. Com- plains of no headache, or pain in spine, save between the shoulders. He cannot * An interesting case of true spinal hemorrhage, with an account of all the then known cases, is given by Dr. Peddie, Monthly Journal of Med. Science, May 1847, p. 819. \ Reported by Mr. Sanderson, Clinical Clerk. STRUCTURAL DISEASES OF THE SPINAL CORD. 435 stand without support, and when he tries to walk he staggers, and would fall if not supported. He can move his legs in bed with tolerable freedom; they often feel cold. Superior extremities unaffected. There is occasional cough, with scanty expectoration. On percussion no dulness is perceptible, on either side, anteriorly. On auscultation, the respiratory murmurs are harsher and louder than natural at apex of both lungs. The urine not albuminous, but loaded with lithates, and sometimes voided with difficulty. Other functions healthy. Progress of the Case.—The paralysis in this man gradually increased. He could not stand, although, when in bed, he could slightly bend the knees and toes. Latterly a swelling formed over the lower dorsal and upper lumbar vertebras, five inches long and three broad. The urine became loaded with phosphates, and, with the faeces, was passed involuntarily. His general health also greatly diminished, painful twitch- ings occurred in the paralysed limbs, emaciation became extreme, the cough violent, the expectoration copious. Several sloughs formed over the left and right hips, not- withstanding he lay on a water bed, and every care was taken to prevent them. Dur- ing the last week in February, and two first weeks in March, an abscess formed above the right clavicle, which opened spontaneously on the 15th of the last-mentioned month, and discharged about 8 oz. of matter. As the respiratory murmur was still heard at the apex of right lung, it was concluded that the abscess originated in the vertebral column. A considerable quantity of pus was subsequently discharged daily, being forced out at each inspiration. March 24th.—He was greatly exhausted, pulse weak and irregular; low muttering delirium at night, with scarcely strength to expectorate. Died the same evening. The treatment consisted at first of a few leeches occasionally applied to the back, of purgatives, and latterly of remedies applicable to spinal symptoms, which produced merely temporary relief. Sectio Cadaveris.—March 26th.—Forty-two hours after death. The body was pale, and greatly emaciated. Over the left hip was a sloughing sore, measuring seven inches in its longest diameter from above downwards, and six inches across. The surface irregular, in some places an inch below the level of the skin, and the whole covered with a dirty greenish ichorous matter. Over the right hip was a smaller slough, of roundish form, about two inches in diameter. Over the vertebral column, between and some- what above these sloughs, there was a circumscribed swelling, of an oval form, five inches long and three inches broad. It was firm and dense to the feel, and on section was found to consist of thickening of the dermis to the extent of three quarters of an inch, combined with oedematous infiltration of the cellular tissue. Opposite to the seventh cervical and first and second dorsal vertebrae, there was a slight angular cur- vature of the spinal column, in the centre of which space externally the skin presented a small purplish discoloration. A fistulous opening, the size of a fourpenny piece, existed about two inches above the centre of the right clavicle. On tracing the open- ing inwards, it led into a cavity which passed behind the subclavian vein, and from thence backwards to the tubercle-of the first rib, which could be felt carious and rough, and from thence to the first four dorsal vertebras, the bodies of which bones were carious throughout. The periosteum had separated from the diseased bones, and formed a pouch anteriorly, filled with pus, which communicated with the external sinus. On examining the diseased bones, their cancellated structure was more or less infiltrated with pus, combined with soft tubercular exudation. The posterior laminae of the first dorsal vertebrae especially were, from the latter cause, of cheesy consistence. Spinal Cord.—The membranes were healthy. Externally the spinal cord pre- sented no appearance of disease. On making a longitudinal section, however, it was found to be distinctly softened internally an inch of its length, opposite the first dor- sal vertebrae. The softened white structure encroached more on the anterior white matter of the cord than posteriorly, and it was of a light fawn color. Thorax.—The pleurae were united by firm adhesions afc the apices of both lungs, and also over the middle on the left side. At the apex of the right lung, the pleurae were also thickened in several places, presenting a white appearance, and the tissue of the lung opposite was much puckered. On section, these puckerings were found to correspond to calcareous concretions, of various sizes, around which numerous hard miliary tubercles of a slate color were grouped. Throughout this lung were numerous similar tubercles, mingled with black pigment deposits and calcareous masses, vary- ing in size from a millet seed to that of a small pea,—most abundant, however, at the apex. Similar tubercles existed in the upper lobe of left lung; but they were not so numerous. The bronchial mucous membrane was much congested; and the larger 436 DISEASES OF THE NERVOUS SYSTEM. bronchi contained copious muco-purulent fluid. The bronchial glands were of black color, and here and there loaded with calcareous matter. Abdominal organs healthy. Microscopic Examination.—The softened portion of the spinal cord consisted of numerous molecules and granules, with the debris of the varicose nerve-tubes of the cord, forming globules of various sizes and shapes, of the white substance of Schwann. Large numbers of compound granule cells and masses were associated with the dis- integrated structures. Commentary.—The preceding case is dependent on a different patho- logical cause, and presents consequently marked variations in the symptoms from the former instances of paraplegia. In it, pressure was gradually made on the spinal cord from without, in consequence of scrofulous caries. The anterior columns of the cord, under such circum- stances, are those which are most injured, and loss of motion is the lead- ing symptom. In Cases XXXIV. to XXXVIL, the first symptoms were numbness or pricking of the toes, followed by perversion or irregularity, rather than loss of motion, and not attended with spasms. This condi- tion is indicative of chronic inflammation of the cord, or myelitis. Pro- fessor Romberg has pointed out a symptom in such persons, which he considers diagnostic of softening of the grey matter in the centre of the cord, as distinguished from lesion of the white matter. This consists in ascertaining that a man cannot stand steadily with his eyes shut. This symptom was well marked in Cases XXXV. and XXXVI., and slightly in Case XXXIV., while everything indicated that it was not so much the conducting, as the tonic power, which was wanting. These considera- tions induced me to try the effects of strychnine, which, however, was of no benefit in Case XXXV., and in Case XXXVI. increased the irre- gular movements when walking, and caused loss rather than increase of power. The galvanic currents, whieh were subsequently tried, also failed in producing any amendment. In case XXXVIII. the caries of the spinal column, but more especially the discharge from the fistulous open- ing, produced the fatal termination. The tubercles in the lung were all in a chronic condition, and although they, combined with the bronchitis, account for the cough and physical signs, they also served during life as indications of the kind of caries present in the vertebral column. The deformity in the dorsal region was only observable a few days before death, and became more marked afterwards. The swelling in the lumbar region was a singular proof of the effects occasionally produced by deep- seated sloughs and cicatrices, in causing local hypertrophy and oedema. Scrofulous or tubercular caries of the bones is a common cause of paraplegia, and considerable difference of opinion exists as to its mode of treatment. It has been maintained, for instance, that caries of a spongy bone never heals, and that where it can be reached, the only remedy is excision. But it has frequently happened that change of air and an im- proved diet have led to the most happy results, and that the caries has healed spontaneously. Every practitioner of experience must have met with cases where caries and distortion of the vertebrae have terminated in anchylosis, and the patient regained his health. Many dwarfs are living examples of the occurrence of scrofulous caries in the vertebral bones having disappeared, leaving them, although deformed, quite well. The theory, therefore, to which I have alluded is incorrect; and although indirectly it has led to many improvements in surgery, by STRUCTURAL DISEASES OF THE SPINAL CORD. 437 causing excision of bones and joints, instead of amputation of limbs, or allowing the patient to sink from exhaustion, there can be no doubt that, notwithstanding, many cases recover under a proper constitutional treat- ment. Thus I have seen some remarkable instances of caries and distor- tion of the vertebrae, which have produced perfect paralysis, and reduced the patient to a great state of weakness. Under such circumstances, in- stead of confining the patient to bed, under the idea that the weight of the body would increase the curvature, I have recommended moderate exercise, given cod-liver oil and nutrients, and the patient has ultimately recovered. During a visit I paid to Germany in 1846,1 saw in the wards of Professor Heusinger of Marburg three such cases at once. They had all had paraplegia. The one most recently treated still had paralysis, the other two, who had been under treatment some months, had recovered, so that they could walk without difficulty, and were nearly well. I saw shortly after, two similar cases in the wards of Professor Jacks of Prague. Hence I am satisfied that our treatment in all such cases should be from the first nutritive and supporting, avoiding depletion and lowering remedies, and insisting on exercise as far as possible by walking or in a carriage. In this way not only may a cure be effected, but in advanced cases health may be sustained and life prolonged, while the tendency to the production of those sloughs on the back, which so commonly hasten the fatal result, is best prevented. Case XXXIX.*—Paraplegia—Cancer of Vertebral bones—Softening of the Cord from Pressure—Cancer of Lung, Liver, and Lumbar Glands —Ulceration of Urinary Bladder. History.—Agnes M'Guire, aet. 60—admitted January 12th, 1849. With the exception of two attacks of fever, had always enjoyed good health until three months ago, when she was seized during the night with nausea, vomiting, and purging. These symptoms continued more or less until a fortnight since, when she first became aware of a feeling of coldness in the lower extremities, especially in the feet and toes. Six days ago, on waking in the morning, she found that she had completely lost all power over the lower extremities, and had a feeling of great weight in the haunches and lumbar region. Symptoms on Admission.—There is great emaciation. The countenance is expres- sive of pain and anxiety. Face and lips pale and sallow. Skin cold and harsh. There is a black slough about three inches in diameter over the sacrum. She com- plains of pain in the breast, chest, and back, and there is tenderness over the abdomen and sides, with tympanitic distension. There is total loss of motor power, and of sensibility from the haunches downwards; but on pricking the soles of the feet, slight spasmodic muscular movements occur. All attempts to move the body, even by others, cause great pain, especially in the lumbar regions. No cough nor expec- toration. Percussion and auscultation over the anterior surface of the chest elicit nothing abnormal; the posterior surface cannot be examined in consequence of the difficulty of moving her. Heart healthy; tongue furred; appetite irregular; con- siderable thirst and occasional nausea. Has passed urine and faeces involuntarily since admission, but says she is generally costive. Urine abundant, and when re- moved by catheter, is of a brick color, with a dark sediment, composed of amorphous urates, triple phosphates, epithelial cells, and blood corpuscles. It is readily decom- posed, and has an ammoniacal odor. Progress of the Case.—This woman gradually became more and more ex- hausted. The slough on the baek became enlarged, the tympanitic condition of the abdomen, with pain there and in the back, underwent occasional remissions, but on the whole never left her. The urine could never be passed voluntarily, and gradu- ally became more loaded with phosphates, blood, and epithelial cells, and emitted an intolerably foetid odor. The bowels for some time were constipated, but diar- * Reported by Mr. J. N. Fanning, Clinical Clerk. 438 DISEASES OF THE NERVOUS SYSTEM. rhoea ensued shortly before death, which took place February 5th. The treatment consisted at first of the occasional application of leeches to the painful portion of the vertebral column, but they never caused even the slightest relief. The constipation was overcome by laxatives, and the urine frequently drawn off by catheter. The slough was constantly dressed with turpentine, and balsamic ointments and poultices, and pressure removed from it as much as possible. Warm bottles were frequently applied to the feet and lower extremities, but they could never overcome the feelin" of cold which prevailed. Internally, nutrients with wine, and latterly brandy, were given. Sectio Cadaveris.—Twenty-five hours after death. Head.—Brain and membranes healthy. Spinal Column.—The bodies of the eighth and ninth dorsal vertebrae were much thickened, presenting an abrupt swelling, and on section were soft from infiltration of encephaloma. The left psoas muscle was adherent to the bodies of the diseased vertebrae, and formed with these a pultaceous disorganised mass, consisting of fatty softened muscle, and broken-down cancerous bone. The body of the third lumbar vertebra was also infiltrated with encephaloma. Spinal Cord.—The diseased dorsal vertebral bones had encroached considerably on the spinal canal, and formed somewhat of an acute angle compressing the cord, which, for the space of one inch opposite them, was reduced throughout to a pulta- ceous consistence. The softening was white, and the membranes surrounding it were healthy. Chest.—In the left auricle of the heart was a hemispherical, flattened, earthy concretion, the size of an almond, embedded in the muscular wall. Heart otherwise healthy. Lungs anteriorly emphysematous. The left lung adherent at the apex posteriorly, on separating which, half of the upper lobe posteriorly was seen to be in- filtrated with encephalomatous exudation of a dirty white, and in some places a light pink color. Throughout other portions of both lungs, nodules of similar encephaloma were disseminated, varying in size from a pea to that of a walnut, and separated by perfectly healthy lung tissue. Bronchial glands of a blackish color, from deposition of pigment, but not cancerous. Abdomen.—The liver, kidneys, and lumbar glands were studded with masses of soft cancer, varying in size in the first-named organ from a hazel-nut to that of a pigeon's egg. The urinaoy bladder was much contracted and corrugated. The inner surface was rough, in consequence of red bloody projections from it, varying in size from a millet-seed to that of a pea. In other places there were injected ruga?, with cracks and ulcerations in the depressions, and considerable depositions of phos- phatic salts. The spleen and other organs healthy. Considerable flatus in the large intestines. Microscopic Examination.—The softened spinal cord consisted of the nerve tubes broken up into minute fragments of various shapes, round, oval, flask-shaped, etc., with double outlines, mingled with a multitude of fatty molecules and granules. A few granule cells were also visible. The cancerous masses in the lung presented broken-up cancer cells, intermixed with numerous granule cells and granular matter, as in the Cancer reticulare of Muller. In the liver, more characteristic cell structures were found ; still, however, here and there mixed with retrograde cancerous masses of a yellowish color. In the bones the cancer-cells were large, many of them con- taining two or three nuclei undergoing development. Commentary.—In this case, encephaloma of various internal organs came on slowly, without causing any distinctive symptoms, until the en- largement of the eighth and ninth dorsal vertebrae from cancerous in- filtration, by pressing on the spinal cord, occasioned incipient symptoms of paraplegia. The two softened vertebral bones, however, sunk suddenly inwards, compressed the cord, and occasioned in the night complete para- lysis, followed sometime afterwards by ulceration of the bladder and sloughs on the sacrum, which caused her death. On dissection, the bodies of the two vertebrae were seen to form an angle, compressing the cord, which was aftei wards reduced to a pulpy consistence, and entirely disorganised. STRUCTURAL DISEASES OF THE SPINAL CORD. 439 The importance of rightly understanding the pathology of structural disease of the spinal cord will be appreciated on reflecting that it gener- ally induces incurable paralysis. Its extent will be greater or less, ac- cording as the lesion involves the origin of a greater or smaller number of nerves, or what amounts to the same thing, cuts off their intercourse with the brain. The recent views of the structure of the cord (pp. 144, 145) further point out to us, that disorganization of the grey matter not only diminishes the evolution of nervous force, but acts directly on the fibres which transmit it to the brain. There is every reason to believe that these fibres not only decussate in the medulla oblongata, but do so all the way down the cord. So small, however, is this latter organ, that diseases of its texture usually affect both halves, and occasion effects on both sides of the body, whereas it has long been a matter of observation, that a lesion on one side of the brain causes paralysis only on the oppo- site side of the body. Hence, in cases of hemiplegia, the disease in the vast majority of cases is referable to the opposite hemisphere of the brain, more especially to the cranial portion of the spinal cord above the de- cussation in the medulla oblongata; whereas paraplegia is as frequently found to depend on disease of the vertebral portion of the cord below that decussation. A very few cases have been recorded, however, in which hemiplegia has occurred on the same side as a lesion found in the brain after death, and which has been supposed to occasion it. Mr. Hilton, indeed, in a paper read before the Royal Society in 1837-38, described a disposition of fibres which he thought capable of explaining such exceptional cases. These, however, are so rare, that it can scarcely be supposed to arise from a permanent anatomical arrangement, and it is far from probable that even in them there is, in fact, no exception to the general law. Thus, numerous instances have occurred of abscesses softening and other morbid changes having been found after death, but in which there was no paralysis during life; and a still greater number are on record, in which there was well-marked paralysis during life, but no appreciable change in the structures after death. It is by no means improbable, therefore, as paralysis may be induced without leaving any traces, that in these few cases it was caused by unknown changes in the opposite hemi- sphere of the brain ; and, as is sometimes the case, that the lesion found in the hemisphere of the paralysed side had produced no effect. Such, we think, is the most probable explanation of these exceptional cases. In the vertebral portion of the cord, although the general rule is, that all those parts are paralysed, furnished by nerves coming off below the seat of disorganization, exceptional cases also have been recorded. In these it has been said that individuals have retained the power not only of moving the lower limbs, but of walking, notwithstanding that the spinal cord has been disorganized throughout its entire thickness. Every one accustomed to pathological examinations must receive with distrust accounts of such observations, knowing how soon this portion of the nervous system may, in certain cases, become softened after death, as well as the injuries it is likely to receive in opening the vertebral canal. Several years ago, I took the trouble to analyse the more remarkable of these cases, and satisfied myself that there was no absolute proof that in any of them the cord was wholly destroyed during life. 440 DISEASES OF THE sNERVOUS SYSTEM. Thus, in the celebrated case of Desault (Journ. de Chir. de Desault, torn. iv. p. 437), the appearance of the parts is not described: it is merely stated, " the spinal marrow was totally divided ; " and the move- ments which took place are thus narrated:—" He was in a continual agitation, and moved the pelvis and inferior extremities even to the last." In all this there is nothing decided. May not the movements have been excito-motory ? Was the altered structure well observed ? The case of M. Rullier {Journ. de Physiol., 1823) has been also frequently alluded to in connection with this question. It was that of a gentleman who had complete and perfect paralysis of the arms, without loss of sensibility and motion in the inferior extremities; he remained in this state six years, and died of pectoral complaints. Dr. Abercrombie, alluding to the case, states that a portion of the cord, six inches in length, occupying two- thirds of the cervical portion and part of the dorsal, was entirely diffluent; so that, before the membranes were opened, it moved upwards aiid down- wards like a fluid. The posterior roots of the nerves of this portion preserved their nervous matter to their junction to the membranes of the cord; but in the anterior roots it was destroyed, and they were reduced to an empty neurilemma. {Abercrombie, p. 350, 3d edit.) This writer mentions that the anterior columns were completely destroyed, and others in alluding to the case have thought a portion of the cord was entirely disorganized. The case itself is headed Disappearance (Disparation) of the Nervous Substance of the Spinal Marrow in the Superior Third of the Dorsal Portion (Ollivier, 3d edit. vol. ii. p. 368), and yet, in the details of the dissection it is stated, " On voyait a peine, vers la partie anterieure de cette portion alteree, les cordons medullaires en rapport avec les racines correspondantes des nerfs spinaux; " and again, " Cette alteration etait beaucoup moins sensible lorsqu'on regardait la moelle par sa face anterieure," etc. From this it would appear that certain continuous fibres still existed in the anterior columns, although they were seen with difficulty, but that there could be no doubt many existed in the posterior. The persistence of voluntary motion and sensibility in the inferior ex- tremities under such circumstances, when the disease too was chronic, is in no way surprising. Instances have also been recorded, in which balls have traversed the vertebral column; or swords have been thrust into the neck, which are said to have entirely cut across the spinal cord, without being followed by paralysis. We cannot here enter into the analysis of these cases, but those who choose to do so will readily come to the conclusion, that no positive proof exists that the cord was wholly destroyed during life. On the other hand, without throwing any doubts on the accuracy of the observations which have been made, may we not consider that the com- plete destruction which has been described, is in some degree a post- mortem appearance caused by partial softening of the cord, mixing after death, perhaps, with the serous fluid always present ? Is it not probable that the necessary violence in opening the vertebral canal may have broken across the fibres, which during life were entire ? Again, may not the movements described in many cases have been excito-motory ? At all events we consider that, in the present state of science, such views are much more rational than to suppose that the influence of voli- tion can leap over four or five inches of disorganized spinal cord in order STRUCTURAL DISEASES OF THE SPINAL CORD. 441 to reach the inferior extremities, or that impressions made on the latter can be communicated to the brain by other channels than the nervous system.* Case XL.f—Neuralgia of the Suborbital Nerve and subsequent Irritation and Paralysis of various Nerves at the Rase of the Cranium, from Can- cerous Disease of the Bones—Catarrhal Pneumonia. History.—Mary Stephenson, set. 32, wife of a shoemaker, admitted January 21st, 1861. Six months ago she received a blow, immediately below the inner canthus of the left eye, directly over the course of the infra-orbital nerve. The injury was fol- lowed by a discharge from the left nostril, which has continued up to the present time. Three months ago she first experienced pain in the gums of the left side, which was attributed to a decayed tooth, and supposed by her to be excited by exposure to cold, whilst carrying water from a distance to her home. The tooth was extracted without causing any relief. A month after, two other teeth were extracted—one of which was decayed—without any benefit. At this time she experienced pricking sensations be- low the left eye, with a feeling as of cold water running over the same place, with diminution of sensibility, and ringing noises in the left ear. Blisters and stimulating applications to the part only produced temporary relief. About three weeks ago the pupil of the left eye became contracted and the vision dim, the left cheek also became swollen. Extract of belladonna was applied round the eye, which caused the pupil to enlarge, and she took three powders daily for five days, which produced salivation. She was also ordered to wean her child, which was now sixteen months old. Expe- riencing no relief, she entered the Infirmary. Her diet has always been good, and her general health excellent. Symptoms on Admission.—She complains of a pricking sensation, often amounting to great pain, and even agony, in the left cheek, darting along the course of the infra- orbital nerve, constant pain below inner canthus. Has paroxysms, consisting of dart- ing pain over the cheek, extending down to the chin and arm. The sensibility of the skin is diminished, over a space extending from the mesial line of the face to the ear laterally, extending upwards, so as to include the inferior eyelid, and below to the margin of the lower jaw. There is partial ptosis of the left upper eyelid, but the lids can be closed perfectly. The pupil of left eye much smaller than the other, and readily contracts on the application of light. The left ala nasi remains open on sniff- ing. There is a slight swelling over the left malar bone. The masseter and temporal muscles act normally. The tongue is clean, and, when protruded, appears to diverge slightly to the left. This is in consequence of the mouth being slightly dragged to the right when in motion; no sensibility to touch on left side of tongue, teeth perfect on both sides. Cannot masticate her food on tfie left side of the mouth; obliged to support her chin with her hand, or the food collects between the cheek and dental arches. The food and saliva occasionally escape from the left corner of the mouth. Tears never produced. On endeavoring to spit, the saliva falls on her clothes, from want of power to project it. In drinking she feels the cup more distinctly with the right half of the lips, and the water feels colder on the left side. The speech is occasionally thick. Headache during strong attacks. Appetite good. Bowels regular. Other functions normal. Progress op the Case.—On the 24th of January, the patient experienced ago- nising pain in the left cheek and left half of the tongue. A blister was ordered to be applied behind the left ear. January 26th.—The pain continues, the blister having caused no relief. The pupil of the left eye is much diminished in size and not movable. Warm fomentations with laudanum to be applied to the cheek. January 21th.—The pain continuing, having in no way been lessened by the laudanum fomen- tations, 20 drops of a solution, containing bi-meconate of morphia, gr. ix. to § j of water, were injected into the cellular tissue of the cheek, below the eyelid. January 28th.— The injection caused considerable stupor, which continued two hours. The head pain has been diminished, she having experienced only two twinges since the operation. January 30th.—Yesterday the pain returned as violently as ever. To * See the Author's Article on Paralysis, Library of Medicine, vol. ii. + Reported by Messrs. W. Turner, W. Spalding, J. Nicholson, and R. Davy, Clini- cal Clerks. 442 DISEASES OF THE NERVOUS SYSTEM. repeat the injection of bi-meconate of morphia. To take Quinice Sulph. gr. v. three times daily. February 12th.—The symptoms have undergone no permanent change; the injections have been repeated eight times, causing only temporary relief. Various remedies were now tried in succession, including the internal use of strychnine, belladonna, iodide of potassium, corrosive sublimate, and anodyne draughts of morphia and chloric ether at night; and, externally, tr. aconiti, mixed with seven parts of gly- cerine, the endermic absorption of muriate of morphia from a blistered surface over the cheek, leeches and galvanism, with only temporary relief. She passed sleepless nights, the discharge from the left nostril was increased, and, between the paroxysms, a constant dull aching pain below the left eye was complained of. On the 23d March she was dismissed at her own request in no way relieved. She was re-admitted April 3d, the symptoms having undergone in the interval little change. Ext. belladonnas was applied round the orbit to dilate the pupil. She was then ordered Sol. hydr. bicMor. § ij, a teaspoonful twice daily, with m. xxx tol. mur. morph. in the form of draught at bed time. April 11th.—Was ordered gum. opii gr. ij at bedtime, which, on April 23d, had been gradually increased to 5 grains. On the 24th ordered 4 grains, which she took until the case fell again under my charge on the 1st of May. The solution of bichloride of mercury was then discontinued, and quinine followed by bebeerine in the form of mixture, were again taken, and Fleming's tr. of aconite once more applied locally, but with only temporary relief. On the 27th of May, the patient was dismissed in no way better. She was again admitted into the Infirmary, December 19th, 1861. After leaving the house she had in succession converging strabismus of the left eye, which was much bloodshot; partial deafness in left ear; loss of sensibility and motion of left side of face; and dragging of the features towards the right side. Four months ago the sight of the left eye was completely gone, and there was permanent ptosis; hearing on the left side had become worse, with constant whirring sounds and throbbing pain in the ear. On assuming the erect posture there has been lately a bloody discharge from the left nostril. Five weeks ago the right eye became affected, and dimness of sight in it has been progressive. Her mind has also become weak and irritable. On admission the features express great pain and anxiety. There is still slight sensibility on the left cheek, but she can pass a piece of paper into the left nostril without causing any tendency to sneeze. The left eyeball is protruded and apparently enlarged. Conjunc- tiva injected. Dense opacity of the cornea, the lower half of which is ulcerated. Pupil dilated. Cannot raise the upper eyelid, but can slightly evert the eyeball. Great deafness in left ear, which is the seat of constant throbbing and singing. Muscles of left side of the face are flaccid, smooth, and apparently swollen, with complete loss of motor power, still necessitating introduction of the finger to remove the food from beyond the dental arches. No smell in left nostril. Occasional giddiness. Sleep disturbed. Left side of palate flaccid, and uvula drawn to the right side. Articulation so much impaired that her words are scarcely intelligible. Occasional excrucia- ting pain. Other functions not affected. January 2, 1862.—Since last report, complains of violent pain in the left eye, occasionally darting into the tongue, over the left temple, and through the parotid. To have 2 grains of codeine in a a pill three times daily. She has subsequently had draughts of chlorodyne at night, and occasionally had chloroform administered to relieve her excessive pain. February 1st.—Again took charge of this case. She was then taking 4 pills daily, each contain- ing a grain of opium, and at night half a drachm of chlorodyne. February 26th.— The left cheek has been occasionally painted with Fleming's tr. of aconite, but without causing any relief. There has also been slight diarrhoea for a few days, and violent vomiting on the night of the 10th. The appetite has diminished, and the nourish- ment taken greatly lessened in quantity. Pulse 100, weak. February 22d.—Less discharge from the nostrils externally, and she complains of its passing backwards and trickling down the throat. From this time she took less and less nourishment. The amount of chlorodyne at night was increased in consequence of the restlessness and great pain. She gradually became weaker, and expired at 1 p.m., February 27, conscious nearly to the last. Sectio Cadaveris.—Twenty-four hours after death. Head.—The brain and its membranes were healthy, with the exception of the latter over the orbital plate of the ethmoid bone, where they were firmly adherent and united to the osseous tissue. The soft spongy tissue of the body of the sphenoid bone, and of the basilar process of the occipital bone, was completely infiltrated with a soft grey- ish substance, which presented to the naked eye the appearance of medullary cancer. NEURALGIA. 443 The compact outer shell of these bones was so softened that a knife could readily be passed through it. The sphenoidal and ethmoidal sinuses were filled with a similar substance. The left side of the body of the sphenoid was completely destroyed, so that the cancerous mass projected into the middle and posterior cranial fossae. In the former of these it had contracted adhesion to the apex of the middle cerebral lobe. In its growth it had involved the third, fourth, fifth, and sixth left cerebral nerves as they passed along the sides of the cavernous sinus. They were all surrounded by the can- cerous material, softened in texture, and evidently infiltrated by it. The fifth nerve was especially included in the diseased mass, so that it was impossible to dissect out its fibres—the nerve before it entered the gasserian ganglion, the ganglion itself, and the three large branches proceeding from it, being involved. The internal carotid artery lying in relation to the inner wall of the cavernous sinus was also included in the tumor, but its canal was pervious. The sympathetic nerves accompanying the artery and forming the cavernous plexus were necessarily involved. The part of the tumor which projected into the posterior cranial fossa was about the size of a hazel-nut. It had extended along the posterior surface of the petrous part of the temporal bone, and surrounded the seventh left cranial nerves as they entered the internal auditory meatus, a small portion passing in along with them. The superior surface of the petrous bone was blackened. In places it was so soft as to be easily cut with the knife. The tumor had grown forwards into the left orbit, and had surrounded all the muscles and nerves which lie in the posterior third of that cavity. The posterior part of the orbital plate of the frontal bone was thickened, softened, and partially destroyed. The tumor projected also into the left nostril, and had pushed to the right side the nasal septum. The bones forming the septum were in great part softened and destroyed. The mucous membrane of the right side of the septum was entire, although commencing to lose its normal appearance. A quantity of dark green, almost black, mucus covered the mucous membrane, which extended from the back of the nostrils into the pharynx. The eighth and ninth cranial nerves were not affected. Although the growth of the tumor was chiefly to the left side, yet it had in part also projected to the right side. The right internal carotid and its accompanying sixth nerve were surrounded by it. The gasserian ganglion of the fifth on this side, together with its ophthalmic and supe- rior maxillary branches, were distinctly involved, but the inferior maxillary branch was very slightly affected. The second, third, and fourth could be dissected out, and no adhesion between them and the tumor was observed.* Thorax.—Heart and pericardium natural. There was a moderate quantity of a gelatinous matter in the bronchi, the lining membrane of which was somewhat congested. Both lungs had inferiorly a somewhat knotty irregular feeling; on being cut into this was found owing to the existence of numerous little patches of catarrhal pneumonia. The affected patches were of a pale yellowish-pink color, slightly granular appearance, softish consistence, and on being squeezed, a small quantity of fluid, resembling pus mixed with air, escaped. Abdomen.—There was no abdominal lesion. Microscopic Examination.—Portions of the tumor selected from the following parts—from the sphenoidal sinus, from within the body of the sphenoid, from the sella turcica, and from the part projecting into the posterior cranial fossa, all presented those cell-forms which are characteristic of soft cancer. The indurated patches of pulmonary tissue were found to consist of epithelial cells and nuclei, mixed with some pus globules. Commentary.—This case, which was under observation for more than a twelvemonth, exhibits remarkably well the progress of a cancerous growth in the osseous substance at the base of the cranium. At first the symptoms of a neuralgia of the suborbital nerve only were present, but as the disease spread, its direction could be accurately followed by its effects on the various nerves it involved. Thus the ptosis, loss of contrac- tility in the iris, and impaired mobility of the eye-ball in some directions, were owing to lesion of the third nerve, while loss of movement in other directions was owing to the disease having attacked the fourth and sixth nerves. Pressure upon the first and second division of the fifth nerve was indicated by the neuralgia, impaired nutrition of the eyeball, and; * The morbid parts were carefully dissected by Mr. Turner, to whom I am indebted for the above facts. They may be seen in the University Museum. 444 DISEASES OF THE NERVOUS SYSTEM. insensibility of the nasal mucous membrane. That the inferior maxillary was involved was proved by paralysis of the muscles of mastication, while the deafness and facial paralysis demonstrated that both divisions of the seventh nerve were affected. In a note concerning this case which Mr. Turner was good enough to give me, he says, " The paralysis of the soft palate may be difficult to find a reason for, seeing that the vagus nerve, which through its pharyngeal branches is its principal motor-nerve, was unaffected. But one of the muscles of the soft palate— viz. the tensor palati—receives a branch from the otic ganglion, which ganglion again receives its motor-root from the third division of the fifth, which was included in the tumor. It may be also, that the soft palato receives a branch from the portio dura, for that nerve gives off a branch, the greater superficial petrosal, to Meckel's ganglion, from which the descending palatine nerves pass to the soft palate. From the fact of both the sympathetic nerve and the ophthalmic division of the fifth being involved in the disease, the case throws additional light on the question, whether the sympathetic or the ophthalmic division of the fifth regulates the nutrition of the eyeball." The phenomena may further be grouped, as they were connected, with special nerve functions:—1st, The increase or loss of common sensibility, of which it may be observed that while the skin was insensible to touch, it was the seat of great pain, a circumstance by no means uncommon in paralysed parts. I have seen the skin also insensible to cold, while morbidly sensitive to beat, so that the numerous tubes which enter a compound nerve may be excited by varied impressions. It is even possible that while some are capable of being excited by motor, and others by sensitive impression, a third class may be stimulated by heat, and a fourth by cold, and others by a variety of peculiar stimuli we have not yet discriminated. 2d, The complete loss of the special sensibility, on the affected side, of smell, sight, hearing, and taste—all the special nerves having been involved in the cancerous growth in the bone. 3d, The paralysis of motion in the fibres of the iris, in those of the levator palpebrae superioris, buccinator, and tongue, from injury to motor-nerves. 4th, The increased secretion from the nostrils and from the salivary glands, but not from the lachrymal gland. 5th, The influence on the vaso-motor nerves, as observed in the redness, increased heat, and even swelling of the left side of the face, especially during a paroxysm of pain. Several of these symptoms even were latterly observable on the right side. And 6th, the effect on nutrition, as observable in the destruction of the eyeball, and progressive emaciation of the tissues of the face on the left side. The multitude of remedies tried in this case not only failed to arrest the disease, which from its nature was scarcely to be expected, but did little to relieve the symptoms. Narcotics, whether employed locally or internally, if in sufficient doses to affect the brain, caused stupefaction and only temporary ease. The pathology of neuralgia, when dependent upon a structural dis- ease, such as the one just related, is clear enough, and consists of pres- sure on the nerve causing irritation and excitement, in the first instance, and loss of function in the second. The same results may be caused by destruction of the nerve (see p. 152); and according to the amount of pressure or disease, even in the same nerve, may the functions of its vari- FUNCTIONAL DISORDERS OF THE NERVOtJS SYSTEM. 445 ous tubules be excited, perverted, or destroyed. In a case I watched with great care at the Salpetriere in 1839, under M. Cruvelhier, it was observed that, whilst the first and third divisions of the fifth nerve were paralysed, the parts supplied by the second division were the seat of excruciating neuralgia. On dissection, considerable thickening of the dura mater existed, where the main trunk of the nerve made its exit from the cranium; and it appeared evident that, whilst the more external tubules were so compressed as to cause loss of function, the more internal were less acted upon, so as to induce excitement. When, however, neuralgia is functional, great discussion has taken place as to the nature of the change producing it. Thus, it may depend upon the temporary conges- tion of some nerve-centre, irritating the root of a nerve, or upon an irritation applied to any part of its course, or even to its extremities. Again, it may be caused by a change in the nutrition of the nerves, in what Du Bois Raymond calls their electro-tonic state. For anything positive as to this last condition, we must wait for the further progress of electro-magnetic pathology. In the treatment of functional neuralgia, all the remedies which were given in the case of Stephenson have been tried with varying success. It should never be forgotten that the pain is most variable and capri- cious in its attacks, with intervals more or less long—a circumstance which favors fallacies as to the value of particular drugs. The disorder also often goes away of itself. Notwithstanding, whenever it exhibits a periodic tendency, which it frequently does, antiperiodic remedies are very beneficial. Of these, I have found bebeerine most valuable. All local anodyne remedies should be tried as palliatives, the beet being Fleming's tincture of aconite, and injection of the cutaneous cellular tissue with a watery solution of bi-meconate of morphia. The applica- tion of narcotic vapor, as recommended by Dr. Downing, I have also seen give great relief. FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM. Case XLI.*—Partial Amaurosis—Spectral Illusions—Perversions of Hearing, Smell, and Touch—Spinal Irritation. History.—Mrs. M'Kenzie, aet. 35—admitted December 30, 1850.—Has been travelling companion to a lady, and always been a delicate and highly nervous person. Nine years ago she had rheumatic fever, and twelve months afterwards her sight became impaired, owing, she supposes, to too much reading at night with gas-light. For this she was freely bled and blistered, and was subjected to a long antiphlogistic treatment by an oculist, without benefit. About the same period the menses became irregular, leucorrhcea was established, and there was great spinal irritation. For these latter complaints I prescribed for her several times, and getting better she went to Canada. From thence she returned four months ago, and feelin^ weak the menstrual discharge also having been excessive during the last four months' she entered the Infirmary. ' Symptoms on Admission.—On admission, she complains of headache and pain in the epigastrium, darting round the left side, and extending to the back. Pressure over the fourth and fifth dorsal vertebrae, corresponding to the painful part, causes acute pain. There is also slight tenderness over the lower lumbar vertebrae. The left pupil is slightly dilated, and vision is much impaired. She does not look straight * Reported by Mr. Henry Thom, Clinical Clerk. 446 DISEASES OF THE NERVOUS SYSTEM. forward at any object placed before her; both eyes being turned to the left of it, almost at right angles. She is much troubled with ocular spectra. She thinks she sees wild animals, flower-gardens, oil paintings, and children dancing before her, dressed in clothes of various colors. She frequently experiences noises in the ears, and especially one like the ringing of a small hand-bell. The sense of smell is also perverted ; a box of strong snuff, for instance, when placed below her nose, having apparently the odor of tea. The sense of taste is not altered. The sense of touch is capable of being perverted by suggestive ideas. On placing a cold piece of metal in her hand, and telling her it was warm, she declared that it was so. Voluntary motion is also impaired. On being addressed suddenly she starts ; and on endeavoring to grasp an object, makes several ineffectual efforts to do so. At the same time, there is considerable tremor and twitchings of the muscles of both arms. There is also great difficulty in walking, from a sense of being pressed down by a heavy weight placed on her shoulders. The tongue is pale, furred, and cracked; there is an acid taste in the mouth, frequent slight difficulty of deglutition, and occasional vomiting about half an hour after taking solid, but not liquid, food. The bowels are opened very irregularly, and there is in ueneral constipation. The urine has a specific gravity of 1005—not coagulable. The men- struation is irregular, and has been latterly profuse. During the last six months it has appeared five times. In the intervals, there is abundant leucorrhcea. On examination with the speculum, the os and cervix uteri were found tumefied. There was no ulce- ration, but copious discharge of purulent matter from the os uteri. The sounds of the heart are natural. Pulse 60, soft. Other organs healthy. A tepid bath was ordered every morning. To use also a vaginal injection of one drachm of alum to eight ounces ofwater ; and to have the following mixture: I£ Ferri Citratis, 3 ss; Tr. Card.-Comp. 5 j ; Tr. Aurantii § ss ; Infus. Columb. % ivss; M.; § ss to be taken three times a day. Progress of the Case.—Under this treatment, and with an occasional laxative, her general health greatly improved. The menorrhagia ceased. The headache dimin- ished; the appetite improved. The spectral and aural illusions ceased to appear, and on the 19th of February she insisted on going out. Commentary.—In this case, conjoined with spinal irritation, there was imperfect amaurosis, one point of each retina only retaining its sen- sibility to light, which point she brought into the axis of vision, by directing both eyes to the left of, and at right angles with, the object examined. With the exception of taste also, all the other senses were more or less perverted. At the same time, the digestive and uterine functions were much disordered; and it was observed in this, as it has been in numerous similar cases, that, as her general strength improved and the dyspnoea and menorrhagia diminished, so did the spectral and aural illusions and other perversions of the nervous system disappear. This fact points out how cautiously the treatment of these cases should be conducted in the first instance, and how dangerous the bleedings, cuppings, purgings, mercurials, etc. etc., must be in certain cases of in- cipient amaurosis, when these are practised (as they too often are) without discrimination or reference to the constitutional powers of the patient. Another curious phenomenon was observed in this case—namely, that her sensations were capable of being governed to a certain extent by suggestive ideas. That is to say, on calling attention to a particular object placed in her hand, and asserting that it was hot or cold (although in reality it was neither), corresponding sensations were produced in her mind. This peculiar condition of the nervous system is one which, it appears to me, is more deserving the attention of medical men than they have hitherto paid to it. It is well known to numerous charlatans, who have ascribed the phenomena so produced to an external power or force, which they could wield at pleasure. Such ideas have done much to shock the minds of physiologists and medical men, and prevent the FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM. 447 proper appreciation of many important facts. Believing, however, that these facts are capable of being explained on physiological principles, and are capable of being rendered serviceable in practical medicine, I would direct your attention to them in a special manner. (See p. 285, et seq.) In no case I ever saw was the inutility of antiphlogistics, mercury, and other modes of active treatment, better demonstrated, even to relieve the amaurosis, for which they were used. In fact, not only the disorder of the retina increased, but so much was the weakness augmented, as ap- parently to induce almost every other form of nervous disorder. On admission to the house her condition was pitiable, and from this she was restored by rest, good diet, chalybeates, cheerful conversation, and confident predictions of her recovery, which evidently had a powerful influence in calming her mind and diminishing the nervous symptoms. The functional derangements of the nervous system are capable of assuming at various times every conceivable disorder of intelligence, sensation, and motion, so that not only may all kinds of diseases which have received names be simulated, but the symptoms may be so curi- ously combined as to set all arbitrary nosological classification at defiance. If it be farther remembered that through the brain, spinal cord, and nerves, the functions of every organ in the body may be more or less influenced, the endless variety of local as well as of general derange- ments will readily be imagined. To illustrate each of these numerous forms of disease by cases is, in a clinical course, impossible; although the wards always present a variety of examples of perverted nervous function. I shall content myself, therefore, with giving a classified enumeration of these disorders, and then dwelling more especially on their pathology and treatment. The functional disorders of the nervous system may be classified into—1st, Cerebral; 2d, Spinal; 3d, Cerebro-spinal; 4th, Neural; and 5th, Neuro-spinal; according as the brain, spinal cord, or nerves are affected alone, or in combination. Aberrations of intellect always de- pend on cerebral disturbance; while perversions of motion and sensi- bility, if extensive, indicate spinal; and if local, neural disorder. Thus insanity and apoplexy are cerebral; tetanus and chorea, spinal; epilepsy and catalepsy are cerebro-spinal; neuralgia and local paralysis are neural; and all combined spasms, dependent on diastaltic or reflex actions, are neuro-spinal. The following enumeration of nervous disorders, with the meanings that ought to be attached to them, will at the same time serve the purposes of definition and of nosological distinctions. Classification of Functional Nervous Disorders. I.—Cerebral Disorders, in which the cerebral lobes {or brain proper) are affected. 1. Insanity, or mental aberration in its various forms, not organic, including delirium. 2. Headache and other uneasy sensations within the cranium, such as lightness, heaviness, vertigo, etc. etc. 448 DISEASES OF THE NERVOUS SYSTEM. 3. Apoplexy. Sudden loss of consciousness and of voluntary motion commencing in the brain. The absence of consciousness necessarily involves that of sensation. The same condition as regards nervous phenomena exists in syncope and asphyxia, but the first of these commences in the heart, and the second in the lungs. Allied to apoplexy is coma or stupor, arising from various causes affecting the brain, such as pressure, or poisonous agents like alcohol, chloroform, opium, etc. etc. 4. Trance, or prolonged somnolence, either with or without perver- sion of sensation or motion. To this state is allied ecstasy, or unconsciousness with mental excitement. 5. Irregular motions, spasms, etc., originating in excited or diminished voluntary power, as in certain cases of dominant ideas, som- nambulism, saltatory movements, tremors, etc., or on the other hand incapability of movement from languor, surprise, mental agitation, etc. etc. II.—Spinal Disorders, in which the cranial and vertebral portions of th spinal cord are affected. 1. Spinal irritation. Pain in the spinal column, induced or increased by pressure or percussion, often associated with a variety of neuralgic, convulsive, spasmodic, or paralytic disorders, affect- ing in different cases all the organs and viscera of the body, and so giving rise to an endless number of morbid states, especially muscular pain, as shown by Dr. Tuman. 2. Tetanus. Tonic contraction of the voluntary muscles. Trismus, if confined to the muscles of the jaws. Opisthotonos, if affect- ing the muscles of the back, so as to draw the body backwards. Emprosthotonos, if affecting the muscles of the neck and abdomen, so as to draw the body forwards; vxAPleurosthotonos if affecting the muscles of the body, laterally, so as to draw the body sideways. 3. Chorea. Irregular action of the voluntary muscles, when stimu- lated by the will. 4. Hysteria. Any kind of perverted nervous function, connected with uterine derangement. Nothing can be more vague than this term. 5. Hydrophobia. Spasms of the muscles of the pharynx and chest, with difficulty in drinking and dread of fluids. 6. Spasms and convulsions. Tonic and clonic contractions of the muscles of every kind and degree, not included in the above, originating in the cord (centric spinal diseases of Marshall Hall). 7. Hemiplegia. Paralysis of a lateral half of the body, generally dependent on disorders of the cranial portion of the spinal cord above the decussation in the medulla oblongata. 8. Paraplegia. Paralysis on both sides of the body, generally the lower half, in consequence of disorder of the vertebral portion of the spinal cord, below the decussation in the medulla ob- longata. FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM. 449 III.—Cerebro-Spinal Disorders, in which the cerebral lobes and spinal cord are both affected. 1. Epilepsy. Loss of consciousness, with spasms or convulsion occurring in paroxysms. Apoplexy with convidsion or paralysis is also cerebro-spinal, though generally organic. 2. Catalepsy. Loss of consciousness, with peculiar rigidity of muscles, so that when the body or a limb is placed in any position it becomes fixed. 3. Eclampsia. Tonic spasms, with loss of consciousness in infants. The acute epilepsy of some writers. IV.—Neural Disorders, in which the nerves are affected during their course or at their extremities. 1. Neuralgia. Pain in the course of a nerve, although in fact all kind of pain whatever is owing to irritation of the nerves. Thus the sympathetic system of nerves and its ganglia, though ordinarily giving rise to no sensation, may occasionally do so, as in angina pectoris, colic, irritable testicle and uterus, and other agonising sensations, referred to various organs. 2. Irritation of the nerves of special sense. Of the optic, causing flashes of light, ocular spectra, musca volitantes, color-blindness, etc.; of the auditory, causing tinnitus aurium ; of the olfactory, causing unusual sensitiveness to odors; and of the gustatory, causing perverted tastes in the mouth. Itching, formication, and other sensations referable to the peripheral nerves, also belong to this class. 3. Irritation of special nerves of motion, as in local spasms of one or more muscles, or of the hollow viscera. 4. Local Paralysis. Loss of motion or sensibility in a limited part of the body, or confined to a special sense, as in lead palsy, or in amaurosis, cophosis, anosmia, ageustia, anesthesia. V.—Neuro-Spinal Disorders, in which both the nerves and spinal cord are affected. 1. Diastaltic or reflex actions. To this class belong all diseases de- pending on irritation of the extremity of a sensitive nerve, acting through the cord and motor nerves on the muscular system, and producing a variety of spasmodic disorders, local or general, far too numerous to mention,—which can only be understood by a thorough knowledge of the physiology of the diastaltic or excito-motory system of nerves. Pathology of Functional Nervous Disorders. By the term functional disorder of the nervous system, I understand one which may produce the greatest pain, spasm, paralysis, and even death, and yet, on the most careful examination afterwards, assisted by the most minute researches with the aid of the microscope, not the slightest change from the normal structure of the nervous tissue can bo 29 450 DISEASES OF THE NERVOUS SYSTEM. observed. Such is what occurs in all the disorders we have named, some of them moreover almost always fatal, such as tetanus and hydro- phobia. At the same time it must not be forgotten, that similar phe- nomena may be the result of structural disease of the nervous system. Thus tetanic rigidity may depend on a spinal arachnitis, as well as on the irritation from a wound, or poisoning by strychnine, and delirium and coma may be caused by cerebral meningitis, as well as by moral in- sanity, starvation, or poisoning by chloroform or opium. Whether in these cases there be in fact only one cause common to the whole, it is difficult to say, certainly it cannot be demonstrated. It might be con- tended that in every instance there is a certain amount of congestion pro- ducing unaccustomed pressure, or that a peculiar state of nutrition of the part is momentarily produced here or there in the nervous mass. But as neither theory appears to us applicable to all cases, we shall consider the pathological causes of functional nervous disorders as of three kinds —1st, Congestive; 2d, Diastaltic; 3d, Toxic. Congestive disorders of the nervous system.—I have previously pointed out the peculiar nature of the circulation within the cranium and verte- bral canal, and shown that, although well defended under ordinary cir- cumstances against any mischievous change, still when an alteration does occur it operates in a peculiar manner. (See p. 148, et seq.) In other words, so long as the bones are capable of resisting atmospheric pressure, although the amount of fluid within these cavities cannot change as a whole, yet the distribution of that amount may vary infinitely. Thus, by its being accumulated sometimes in the arteries, at other times in the veins, or now in one place and then in another, unaccustomed pressure may be exercised on different parts of the nervous centres. This, accord- ing to its amount, may either irritate or suspend the functions of the parts, a fact proved by direct experiment, as well as by innumerable in- stances, where depression of bone has caused nervous phenomena, which have disappeared on removal of the exciting cause. That congestion does frequently occur in the brain and spinal cord, there can be no doubt, although it cannot always be demonstrated after death. The tonic contraction of the arteries is alone sufiicient to empty them of their contents, and turgidity of the veins may or may not remain according to the symptoms immediately preceding death, and the position in which the body is placed. But it is observable that all causes which excite or diminish the action of the heart and general powers of the body, induce, at the same time, nervous disturbance, by occasioning a change of cir- culation in the cerebro-spinal centres—such as the emotions and passions, plethora and anemia, uterine derangement, etc. etc. It is only by this theory that we can understand how such various results occasionally occur from apparently the same cause, and again how what appear to be different causes produce similar effects. Thus violent anger or an unaccustomed stimulus may, in a healthy person, induce a flushed countenance, increased action of the heart, a bounding pulse, and sudden loss of consciousness. Again, fear or exhaustion may occasion a pallid face, depressed or scarcely perceptible heart's action, feeble pulse, and also loss of consciousness. In the first case, or coma, there is an accumulation of blood in the arteries and arterial capillaries, and a corre- FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM. 451 sponding compression of the veins; in the second case, or syncope, there is distension of the veins and venous capillaries, with proportionate di- minution of the calibre of the arteries. In either case, owing to the pecu- liarity of the circulation within the cranium, pressure is exerted on the brain. Hence syncope differs from coma only in the extreme feebleness of the heart's action—the cause, producing loss of consciousness, sensa- tion, and voluntary motion, being the same in both. Indeed, it is some- times difficult to distinguish these states from each other, and that they have frequently been confounded does not admit of doubt. In the same manner, partial congestions from either cause may occur in one hemisphere, or part of a hemisphere, in the brain, or in any par- ticular portion or segment of the spinal cord. The pressure so occasioned may irritate and excite function, or may paralyse or suspend it'; nay, it may so operate as to suspend the function of one part of the nervous system, "while it exalts that of another. Thus all the phenomena of epilepsy are eminently congestive, the individual frequently enjoying the most perfect health in the intervals of the attack, although the effects are for the time terrible, causing such pressure, that, while the cerebral functions are for the time annihilated, the spinal ones are violently ex- cited. In the same manner are explained all the varied phenomena of hysteria and spinal irritation, for inasmuch as the spinal cord furnishes, directly or indirectly, nerves to every organ of the body, so congestion of Uiis or that portion of it may increase, pervert, or diminish the functions of the nerves it gives off, and the organs which they supply. Congestion, therefore, we conceive to be the chief cause of functional nervous dis- orders originating in the great cerebro-spinal centre. Diastaltic or Reflex Disorders of the Nervous System.—We have pre- viously seen that recent researches render it probable that the actions hitherto denominated reflex are in fact direct (p. 145), only that the im- pression which is conveyed commences in the circumference of the body, instead of in the nervous centres. There is every reason to believe that such impressions pass through the cord by means of conducting nerve- fibres, which cross from one side of that organ to the other, and that histology will yet demonstrate that all these apparently confused actions are dependent on the existence of certain uniform conducting media. Indeed, already we can judge with tolerable exactitude, from the effects, what are the particular nerves and segments of the cord which are in- fluenced during a variety of actions ; and notwithstanding the immense difficulties of the inquiry, we have every hope that the period is not dis- tant when the diagnosis of many more reflex acts will also be rendered certain. The principle involved in all these acts is, that the irritation which produces them is to be sought for in the nervous extremities rather than in lesions of the centres; and the great importance of this principle in pathology and in practice cannot be too highly estimated, although for the numerous details which illustrate it, I must refer to physiological works, and especially to those of Dr. Marshall Hall. I would point to traumatic tetanus and to the convulsions resulting from teething and gastric derangements in children, as good examples of dia- staltic functional disorders. 452 DISEASES OF THE NERVOUS SYSTEM. In addition to important diseases of this kind, numerous symptoms which accompany organic changes belong to the same category. In other words, the structural lesion constitutes the irritant, or cause, while the effect is functional. Thus I have seen epileptic opisthotonos, after resist- ing for years every kind of remedy, at once removed on extracting a decayed tooth. In the case of Joanna M'Gregor, admitted Dec. 4th, 1856, there was hysterical epilepsy, which resisted all treatment, and among the rest, a long-continued use of the bromide of potassium, recently recommended by Sir Charles Locock in such cases. The attacks of uni- versal rigidity, with tremor and complete unconsciousness, usually lasted from three to four hours. It was observed, however, that immediately before coming out of the attack she was seized with suffocative cough, accompanied by great turgidity and redness of the face. It was thought that by exciting such cough artificially, the attacks might be shortened. Galvanism was in consequence applied to the larynx the moment she was seized, with the effect of at once exciting cough, flushing of the face, and immediate recovery. In this case, the spasm of the larynx, which was an excito-motory act, by producing a change in the circulation within the cranium, dispelled the congestion causing the epileptic paroxysm. Again, those compound effects which require the conjunction of voli- tion with diastaltic acts are most interesting to the scientific practitioner —such, for instance, as coughing, yawning, laughing, hiccough, and sneez- ing. Cough more especially is a frequent and most distressing symptom, and, as we shall subsequently see, requires for its successful treatment a thorough knowledge of the causes producing it. If, for instance, it ori- ginates in irritating disease of the larynx, what permanent benefit can be produced by giving opiates which act upon the brain ? Toxic Disorders of the Nervous System.—The influence exercised by certain drugs is of a kind which causes a close resemblance to various diseases of the nervous system. These influences, if carried to excess, are toxic, and dangerous to life; if employed moderately and with caution, they constitute the basis of our therapeutic knowledge in a vast variety of diseases. Why one drug should possess one power, and another a different one, or why some should influence the brain, and others the spinal cord or nerves, we are ignorant. Such facts are as much ultimate facts in therapeutics as are the separate endowments of contractility and sensibility in physiology. (See p. 344, et seq.) As pathological causes of functional disorders of the nervous system, their power is undoubted. By their means the five classes of nervous disor- ders may be occasioned in different ways, producing altogether distinct and peculiar effects. Thus— Cerebral Toxic Disorders are occasioned by opium and most of the pure narcotics, which first excite and then depress or destroy the mental faculties. According to Flourens, opium acts on the cerebral lobes, while belladonna operates on the corpora quadrigemina. The first causes con- traction, and the last dilatation of the pupils. Tea and coffee are pure excitors of the cerebral functions, and cause sleeplessness. Alcoholic drinks, ether, chloroform, and similar stimulants, first excite and then suspend the mental faculties, like opium. The modern practice of de- FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM. 453 priving persons of consciousness, in order, for a time, to destroy sensation, has been very much misunderstood, in consequence of such remedies having been erroneously and unscientifically denominated anaesthetics. The fact is, they scarcely influence local sensibility, or the sense of touch. Their action is cerebral, and hence the danger which occasionally attends their administration. Spinal Toxic Disorders.—Strychnine acts especially as an excitor of the motor filaments of the spinal cord, causing tonic muscular contrac- tions, as in tetanus from spinal arachnitis, or from the diastaltic action of a wound. Woorari produces exactly an opposite effect, causing para- lysis and resolution of the same parts. Conium paralyses the motor and sensitive spinal nerves, producing paraplegia, commencing at the feet and creeping upwards. (See case of Gow, p. 460.) Picrotoxine, according to Dr. Mortimer Glover, causes the animal to stagger backwards, as in the experiments of Magendie on the Crura Cerebelli. Cerebro-Spinal Toxic Disorders.—Of these the poisonous effects of hydrocyanic acid offer a good example. All the animals I have seen killed by this agent utter a scream, lose their consciousness, and are con- vulsed. These are the symptoms of epilepsy. Cold is at first an excitor of the spinal functions, and is a strong stimulant to diastaltic activity, but, if long continued, produces drowsiness and stupor. Neural and Neuro-Spinal Toxic Disorders are especially occasioned by the action of certain metallic poisons, such as mercury, which occasions irregular muscular action with weakness, and lead, which causes numb- ness and palsy, most common in the hands. On the other hand, can- tharides stimulates the contractions of the neck of the urinary bladder, and secale cornutum those of the pregnant uterus. Stramonium acts as a sedative to the nerves of the bronchi, while aconite operates powerfully in paralysing the action of the heart. Treatment of Functional Nervous Disorders. The great principle in the treatment of congestive disorders of the nervous system appears to be, the necessity of increasing the strength and nutrition of the body by all practicable means. Such, indeed, has been the general practice—the mineral tonics, and more especially chaly- beates, being the chief remedies administered in such cases, conjoined with the various preparations of quinine, bark, and the vegetable bit- ters. Stimulants of all kinds, and especially the anti-spasmodics, have also been liberally administered. It must be confessed, however, that not unfrequently antiphlogistics, with general and local bleedings, espe- cially the latter, have occasionally been employed. Formerly it was supposed, and I shared in the opinion, that functional nervous disorders might depend upon both an increased and a diminished vital power of the economy, and that for the former a lowering, and for the latter a supporting plan of treatment would be necessary. Experience, how- ever, has satisfied me, that if the former cause ever operates at all, it is extremely seldom, and that nervous disorder is almost always a symptom of exhaustion. The relief of pain, more especially in cephalalgia and spinal irritation, 454 DISEASES OF THE NERVOUS SYSTEM. appears to follow laws which have by no means been determined. Thus two or three leeches applied over the part often effect this object, under circumstances where it is impossible to imagine that they can have diminished the congestion. How, for instance in cases of head- ache, if it be dependent upon congestion of the brain, can an ounce of blood, drawn by leeches from the vessels of the scalp, act in this way? It has often appeared to me, that the warm fomentations, usually applied to the leech-bites afterwards, are more effectual than the loss of blood, and that the therapeutic action is really reflex in its character. For the same reason, dry is often as effectual as wet cupping. The influence of heat and cold is most important in relieving all kinds of nervous pain, and has been previously referred to. (See p. 327.) As a true anaesthetic, or destroyer of local sensibility, congelation has been shown by Dr. James Arnott to be a most successful and manageable remedy. I have used it in the way he has recommended with excellent effect in a variety of local painful affections, and join him in condemning the use of chloroform in cases where this safer pro- ceeding can be employed. Why remove the consciousness of an indi- vidual by deep intoxication, with all its attendant risks, when the same effect can be produced by immersing the parts in a mixture of powdered ice and salt, without any risk at all ? Counter-irritation is also most useful in the relief of chronic con- gestive nervous disorders, and not unfrequently produces a cure. This is well observed in certain cases of spinal irritation, in which the local pain is often made to shift its position, and if followed by other blisters, is at length got rid of. I once ordered a blister to be applied over some painful dorsal vertebrae, in a young lady, who had long suffered from dyspnoea, cough, and supposed phthisis. Next day I found her breathing easily, with no pain in the back, which, however, had shifted to the occiput, and occasioned trismus. Another blister applied to her neck perfected the cure. On other occasions, the disappearance of pain in one part of the back will bring on sudden aphonia, palpitation, colic, or other symptoms, which in their turn yield to further counter- irritation. The great principle in the treatment of diastaltic disorders of the nervous system is to remove the peripheral source of irritation from which they arise. Thus, cutting the gums, diminishing acidity in the stomach, or removing undue accumulations in the intestines, are the appropriate means for combating the convulsive disorders of infancy and childhood. Attacks of hydrophobia, epilepsy, and tetanus, may frequently be prevented by attention to the local causes which induce these disorders. Hysteria is always associated with uterine derange- ment, to which the practitioner's attention should chiefly be directed, whilst innumerable spasms and convulsions may be traced to carious teeth, disease of the larynx or pharynx, indigestible food, worms, pecu- liar habit3 and occupations, etc. etc., on the removal of which the cure depends. The ready method of applying numerous remedies for the cure of morbid states or particular symptoms is dictated by our knowledge of excito-motory actions, and owes all its importance to the labors of Dr. FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM. 455 Marshall Hall. Thus dashing cold water on the face and general sur- face in syncope, or in the suspended animation of the new-born; the irritation of the fauces to excite vomiting; the avoidance of this irrita- tion, by pushing the bolus rapidly into the pharynx when our object is to excite deglutition; and the series of operations lately proposed to recover asphyxiated persons, are all of this character. In 1856,1 observed in a young woman with strong epileptic attacks, that on passing a galvanic shock through the larynx, the paroxysms ceased immediately. I have repeated this practice frequently since, but have only found it to succeed in hysterical women. Such is its marked effect, however, in this class of cases, that I have no hesitation in recommending it as highly useful, at once arresting the convulsion or spasm, preventing exhaustion, and thereby more rapidly causing recovery. This result, however, is by no means invariable; and in one case where it failed, the spasms (complete opisthotonos) were immediately stopped by dashing cold water freely over the face and chest. Whichever stimulant be applied, there can be no question that, whenever the con- vulsion can be controlled, its employment is highly conducive to recovery. The great principle in the treatment of toxic disorders of the nervous system is to support and stimulate the strength of the patient, until the action of the poison is exhausted. This subject will be best illustrated by examples :— Case XLIL*—Delirium Tremens—Recovery. History.—Peter Fraser, set. 56, an engraver—admitted September 22, 1851. He has generally enjoyed good health. For some time his habits have been very intem- perate, and he has had much domestic annoyance. A year ago he had an attack of delirium tremens. During the last few weeks he has been drinking considerably, although he says not to excess. Fourteen days ago he began to feel very restless and uneasy while at work, and his sleep during the night became disturbed, but he has had no tremors or spectral illusions of any kind. Symptoms on Admission.—He now complains of severe pain in the head, referred principally to the frontal region. No pains in any other part of the body. His hands when put out have a trembling fidgety motion, but when kept by his side are steady. Tongue is moderately dry, and covered with a whitish fur. Bowels are generally costive, but were open yesterday. Action of the heart hurried, and occa- sionally irregular; impulse strong. Pulse 96, full and strong. Other functions normal. E Sol. Mur. Morph. 3ij; Vin. Antimon. 3j; Tinct. Aurantii, 3j; Aqum 3 j. Ft. haustus hora somni sumendus. Progress of the Case.—September 23.—Notwithstanding the draught, passed a restless night. Bowels not open since admission. Pulse 90, of moderate strength. I£ Pulv. Rhei. Co. 3j ; Aq. Mentha;. Pip. § j ; Ft. haustus statim sumendus. Sep- tember 24.—Passed a more quiet night. Bowels open. From this time all tremor in the hands and cephalalgia left him. He was dismissed quite well, September 27. Cass XLIII.f—Delirium Tremens with Ocular Spectra—Recovery. History.—Elizabeth Banks, aet. 34, married—admitted April 1, 1851. She states that a fortnight ago she was suddenly seized with pain in the head, trembling and dizziness, so that she was obliged to be supported. She ascribes the attack to the receipt of unpleasant intelligence. There have been several of these attacks * Eeported by Mr. Scott Sanderson, Clinical Clerk. f Eeported by Mr. W. H. Pearce, Clinical Clerk. 456 DISEASES OF THE NERVOUS SYSTEM. since, during some of which, her husband says, she has been very violent in her attempts to escape from imaginary enemies. She confesses to have been for some time addicted to spirit-drinking, and states that up to the time of this illness she has enjoyed good health. Symptoms on Admission.—She has a healthy but somewhat restless appearance. She answers questions rationally and is quite calm, remembering everything that has occurred, except during the sudden attacks of trembling, etc. She has pain over the whole head; there is, however, no heat of scalp or suffusion of the eyes. The pupil is natural, and the iris contracts readily. She sees various things before her, especially different kinds of animals running about, which are most numerous and vivid at night. She feels also at times as if persons were making attempts upon her life. For the last three nights she has had no sleep, in consequence of these ocular appearances. Her hands are very unsteady, and the fingers are constantly playing with the bed-clothes. Pulse 90, of good strength. Tongue furred, and rather dry. Bowels habitually constipated, and unrelieved for three days. Other functions nor- mal. R Elaterii gr. ss.; Pulv. Gamb. gr. ij ; Potass. Bitart. gr. x; Ft. pulvis statim sumendus. ^ Sol. Mur. Morphias 3 j ; Aqua; 3 vij ; Ft. haustus hora somni sumendus. Progress op the Case.—April 8.—Has slept tolerably during the night. Is not so restless, and has seen few ocular spectra. The hands and her whole appearance calm. The purgative powder only occasioned one stool. From this time she gradu- ally recovered, and was discharged quite well on the 24th. Case XLIV.*—Delirium Tremens with Convulsion and Coma—Recovery. History.—David Seaton, set. 25, a chimney-sweep—admitted on the evening of September 10, 1849. His friends state that he has been greatly addicted to the use of spirits, and that during the last three months he has had several apoplectic attacks. He has, notwithstanding, continued to indulge in drink; was this morning extremely violent, and during the afternoon became insensible. Symptoms on Admission.—On admission the countenance is bloated and flushed, and his short stout figure gives evidence of great strength. He is now comatose, breathes stertorously; pulse 60, full and strong. The head, to be shaved, 12 leeches to be applied, a drop of croton oil to be placed on the back of the tongue with sugar, so as to ensure deglutition, and to be repeated in an hour if necessary.. Progress op the Case.—September 11.—During the night he several times par- tially recovered his senses, and again relapsed. To-day is much better, and can answer questions in a confused way. Four drops of croton oil have been given, and operated once. To have one drachm of sol. of muriate of morphia at nigh. Sep- tember 12.—Violent delirium during the night, with insomnolence. It became neces- sary to employ the strait waistcoat. Pulse quick and feeble. Ice-water to be applied to the head. One drachm of sol. of muriate of morphia to be repeated at night. To have a turpentine enema. September 13 and 14.—No improvement. September 15.— Is somewhat sensible; pulse rapid and feeble. To discontinue the morphia. To have §j of whisky ev/sry two hours. September 16.—Slept a little last night. To-day talks sensibly. Pulse 80, stronger. Bowels opened by means of an injection. From this time he gradually recovered, and was dismissed well, September 21. Case XLV.f—Coma and Death from Excessive Drinking—Opacity of Arachnoid—Subarachnoid Effusion—Fluid Blood. History.—James Dick, set. 48, a joiner—admitted on the evening of January 31, 1851, in a moribund condition. He has been habitually intemperate for many years. For the last week has been in a constant state of intoxication. This evening became Buddenly ill, and lost his consciousness. Shortly afterwards he was conveyed to the Infirmary. Appearance on Admission.—On admission he presented all the appearance of a corpse. No breathing was perceptible; no beating of the heart could be heard with the stethoscope. The countenance pale ; head thrown back; mouth open and frothy; eyes turned up, and pupils dilated. All efforts at re-animation were of no avail; he was dead. * Reported by Mr. Alexander Christison, Clinical Clerk. f Reported by Mr. Sanderson, Clinical Clerk. FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM. 457 Sectio Cadaveris.—Thirty-eight hours after death. Body well formed and strong, not emaciated. A little tumidity of depending parts. Head.—On removing the calvarium, the subarachnoid tissue was seen to be in- filtrated with fluid, raising the arachnoid to the level of the convolutions. The sinuses were distended with fluid blood. The cerebral arachnoid presented considerable opacity all over the hemisphere, in some places diffused, in others exhibiting minute points closely aggregated together. The ventricles contained a small amounUof fluid, and several simple cysts in the choroid plexuses. Cerebral arteries and other portions of the brain perfectly healthy. Chest.—Both pleurae contained several ounces of serum, and were slightly adherent at the apices. Both lungs were healthy, with the exception of unusual engorgement, posteriorly and inferiorly. A cretaceous concretion, the size of a barley-corn, in apex of right lung. Bronchi contained a moderate quantity of frothy mucus, which was more abundant in trachea and larynx. Pericardium contained one drachm of serum. Heart healthy. The blood in the cavities and large vessels remarkably fluid. Abdomen.—The liver pale in color, and very soft, weighed 3 lbs. 14 oz. A few serous cysts in the kidney. Other abdominal organs healthy. Microscopic Examination.—The cells of the liver were loaded with oil granules of large size. The tubercles of the kidney here and there also contained several fatty granules. Cerebral substance healthy. Commentary.—Various opinions as to the nature of delirium tre- mens have been held by medical men, who have successively placed it among the neuroses, the phlegmasiae, and the pyrexiae. Until recently, it was held that whilst drinking was its predisposing cause, the sudden abstraction of the accustomed stimulus brought on the attack. This theory was successfully combated by Dr. Peddie,* who has shown that the disease is seldom observed in our prisons, notwithstanding the large number of confirmed drunkards admitted there and immediately placed upon low diet. The view of its pathology now prevalent is, that alcohol, a poison dangerous to life in large doses, is also cumulative taken habitually in small quantities. Like many others, it is one which especially affects the nervous system, and more particularly the brain, as shown by Percy, Huss, and other writers. Hence those effects deno- minated intoxication, delirium tremens, etc. Formerly the treatment used to consist of supplying the accustomed stimulus; but theoretically it is clear that this is tantamount to adding coals to fire, and practically it has been shown that patients more rapidly recover under the use of nutrients. In the vast majority of cases of delirium tremens, the poison becomes eliminated from the system in a certain time; whether anti- mony, in half or quarter grain doses, assists this process, as was at one time supposed, is very doubtful. Generally speaking, if a good sleep can be obtained, it is critical, and the patient at once recovers. Opium has been largely given to obtain this result, but its supposed beneficial action is generally coincident with the muscular fatigue, exhaustion, and tendency to repose which accompany the elimination of the alcoholic poison. I have been so struck with the increase, rather than the dimi- nution of the symptoms, by all attempts at medication, in the early stage of the disorder—a circumstance observable in the cases recorded —that for the last ten years I have given little but nutrients, and every case has recovered. During the summer of 1864 I strongly pointed this out; and every case admitted during May, June, and July of that year was carefully recorded. They all recovered as follows:— Monthly Journal of Med. Science, June, 1854. 458 DISEASES OF THE NERVOUS SYSTEM. 1 No. Name. M. Age. Admitted. Symptoms. Treatment Dismissed. 12th May. 1 T. Eadie 49 5th May. Mild. Good diet—rest. 2 J. Borthwick. M. 49 19th May. Well marked—4th attack. Do. do. 24th May. 3 F. Hastie. M. 44 19th May. Mild. Do. do. 24th May. 4 J. Calder. M. <7 24th May. Mild. Do. do. 27th May. 5 G. G-illiB. M. 33 25th May. Violent. Tied down in bed—beef tea and nutrients. 31st May. 6 J. Adair. M. 40 28th May. Mild—3d attack. Beef tea and nutrients. 1st June. 7 W. Gordon. M. 47 29th May. Mild—2d attack. Do. do. 1st June. 8 R. H. Whitten. M. 54 9th June. Well marked—had other attacks. Tied in bed—good diet. 16th June. 9 Thos. Robb. M. 55 11th June. Well marked. Do. do. 16th June. 10 T. Dickson. M. 48 12th June. Mild. Good diet—rest. 15th June. 11 W. M'Donald. M. 43 17th June. Comatose on ad-mission. Emetic first—good diet. 20th June. 12 B. M'Gintie. M. 50 19th June. Mild. Good diet—rest. 28th June. 13 W. Simpson. M. 44 20th June. Severe. Emetic first—good diet. 1st July. 14 M. Bell. F. 24 21st June. Severe. Tied 'in bed—emetic— good diet—rest. 5th July. 15 M. Coverdale. F. 40 3d July. Mild. Good diet—rest. 13th July. 16 D. Davies. M. 44 4th July. Mild. Tied in bed—rest—good diet. Do. do. do. 12th July. 17 D. Wallace. M. 47 6th July. Severe. 12th July. 18 M. A. Smith. F. 34 18th July. Severe. Do. do. do. 28th July. 19 P. Forrest. M. 30 20th July. Mild. Good diet—rest. 22d July. 20 J. Brown. M. 52 21st July. Mild. Do. do. 30th July. I hold, therefore, that delirium tremens is one of those diseases that only requires a dietetic treatment, and that the sooner nutrients can-be taken, the more rapid is the recovery. It is of great importance that the windows and doors of the room in which patients with delirium tremens are should be well closed, because, although there is no violence, a tendency to escape from imaginary enemies has led to some deplorable accidents. Personal restraint should be avoided as much as possible. Case XLVI.*—Poisoning by Opium—Recovery. History.—Helen M'Dermott or Cuthbertson, Bet. 33, but looking ten years older, residing in the Cowgate as the wife of a cooper, was admitted at 3 p.m. May 25, 1857. She has not unfrequently been drunk, and had a quarrel lately with her husband. On the preceding day she had gone out and purchased two ounces of laudanum, namely, one ounce at two different druggists' shops, and had swallowed them (it is said) half an hour before admission. Symptoms on Aomission.—On admission, contracted pupils, great drowsiness, re- laxation Of muscles, and tendency to cold ; with lividity of face and extremities. The stomach-pump was employed to wash out the stomach; this was first done with warm water, and twice subsequently with mustard and water. The first vomited matters smelled of laudanum. The patient was stimulated to walk about until toward 4.30 p.m. By that time her limbs became so relaxed that she sank to the ground; and she was so drowsy as to fall asleep unless pushed or pricked. The galvanic battery was then applied to the popliteal spaces, and to the hands, breast, and neck— (Kemp's battery being the instrument employed). Meanwhile, as patient was in bed, warmth was maintained by clothes and hot bottles. Under stimulus of the battery, patient was also induced to swallow some coffee. At 6.30 p.m. she was so easily roused by galvanism—the skin warm, the pulse (small and weak before) becoming more perceptible and strong—that the stimulus was more rarely applied, merely to prevent the sleep into which from time to time she fell from becoming profound. At 8 p.m. a drachm of brandy, and half a drachm of Sp. Ammon. Aromat. were admini- stered, to be repeated every hour. During the first three administrations of this stimulant vomiting occurred, the vomited matter consisting of the coffee that had previously been swallowed. At ten, eleven, and twelve, she was seen dozing slightly, but was easily roused. Next morning complained of sickness, and of not having been * Reported by Dr. John Glen, Resident Physician. FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM. 459 able to sleep during the night; was quite conscious and thankful for her recovery. Slept during the day, taking tea and beef tea. On the 27th, having fully recovered, she was discharged. Case XLVII.*—Poisoning by Opium—Recovery. History.—Robert Cooper, aet. 41, admitted June 24th, 1864, a laborer, in the habit of drinking to excess. After leaving off work on the evening of the 20th, he commenced drinking, and continued to do so until the evening of the 24th, when he was brought to the Infirmary by some men, one of whom said he had seen him go into three druggists' shops. Two hours before admission he was found fast asleep in the street, and as he could not be awakened, was brought to the Infirmary. In his pockets were two bottles, one capable of holding §j, the other §vi, both strongly smelling of laudanum. Symptoms on Admission.—Pupils contracted to the sixteenth of an inch in diameter, insensible to light. There is profound coma, face pale, pulse weak. A stomach-pump was immediately procured, and the stomach emptied of its contents, which smelt of laudanum. It was filled four times with water, and again emptied. Then a strong infusion of coffee was administered. Three-quarters of an hour after- wards he appeared to be slightly conscious, and answered questions indistinctly. On the following morning the surface was bathed in perspiration, pupils still contracted, but slightly sensitive to light. Answers questions, but is oblivious of everything that happened since the 22d. Easily relapses into drowsiness and sleep. To have beef tea and nutrients. From this time slowly recovered, and was dismissed on the 28th. The matter pumped out from the stomach, on being analysed by Dr. Duckworth, was found to contain muriate of morphia in large quantity. Commentary.—The symptoms of poisoning by opium are first cere- bral, and secondly spinal, the danger to be apprehended being great depression of the vital powers. Our first efforts should be directed to removing as rapidly as possible the poison from the stomach, and to this end the pump should be employed, in preference to emetics. Indeed, in most cases, coma renders deglutition difficult. After this it was formerly the habit of trying to rouse the patient by walking him about, shaking him, or administering galvanic shocks. All these processes, as they tend to produce exhaustion of the vital powers, cannot be regarded as judi- cious. Our object ought to be to support the strength and action of the heart as long as possible, with a view of permitting the poison to be eliminated. Accordingly, it will be observed that the second case recov- ered rapidly, without having recourse to any such expedients. Another idea is that some antidote should be administered, supposed to be capa- ble of rousing the brain. Thus, in both cases recorded, a strong infu- sion of coffee was administered. In 1859, my then resident physician. Dr. Carter, now of Leamington, injected a solution of atropine into the cellular tissue, as a supposed corrective to the effects of opium. Coffee or tea can do no harm, but it is much to be doubted whether theoreti- cally their employment can be defended (see p. 345) as being useful. Experience and careful experiments up to this time have failed to give us any positive information on the subject. Case XLVIII.f—Poisoning by Hemlock—Death. History.—On Monday, April 21st, 1845, about seven o'clock in the evening, a man, called Duncan Gow, was brought into the Infirmary by two policemen. It was * Reported by Mr. D. Thomas, Clinical Clerk. f Published by me in the Edin. Med. and Surg. Journal, No. 164. 1845. 460 DISEASES OF THE NERVOUS SYSTEM. stated that he had been found lying in the street, apparently in a state of intoxication, or in a fit. On being taken into the waiting-room, he was found to be dead. I subsequently learnt from his wife that the man, forty-three years of age, a tailor by trade, was in such reduced circumstances that he had not eaten anything on Mon- day, until he took the substance which caused his death. Two of his children, a boy and a girl, aged respectively ten and six years of age, found what they took for parsley growing on the bank under Sir Walter Scott's Monument (which was then building), and knowing that their father was very fond of this, as well as of other green vegeta- bles, they gathered some to take to him. On visiting the place with the boy, four days afterwards, I found that the spot from whence the plants were gathered had been covered over with fresh rubbish. But on the uncovered part of the bank, eighty yards westwards, the Conium maculatum could be seen growing in considerable quantity. The children returned home between three and four o'clock p.m. The father, who had fasted the whole day, greedily ate the vegetables, together with a piece of bread, and said more than once how good they were. The quantity consumed could not be ascer- tained, for he ate nearly all that was brought. On finishing his meal, he rose, saying he would endeavor to get some money, in order to procure food for his children. At this time he was in perfect health. From his own house, at the head of the Canongate, Gow walked about half a mile to the house of one Wright, in the West Port, with a view of selling him some small matter. Wright, on his entering the room, thought at first that he was intoxicated, because he staggered in walking. On passing through the door also, which was nar- row, he faltered in his gait, and afterwards sat down hastily. He stayed ten minutes, during which time he conversed readily, drove a hard bargain, and obtained fourpence for what he sold. He did not complain of pain or uneasiness, was not excited in man- ner or speech, and his face was pale and wan. On rising from his chair, he was ob- served by Wright's boy to fall back again, as if he had some difficulty in rising. On making a second effort he got up, and was seen by Wright's wife to stagger out of the house and down the steps. This was a little after four o'clock. On leaving Wright's house, he was next seen standing with his back against the corner of the street, by Andrew Mc'All, a meal-dealer in the Grassmarket, about 200 yards from Wright's house. Mc'All saw him leave the corner he was leaning against, and stagger to a lamp-post a few yards further on. Here he again paused for a few minutes, and then again went forward in the same vacillating manner, passed Mc'All's shop, and sat down at the opening of the common stair next to it. Mc'All's words are, " He could not walk rightly, and was staggering as a man in liquor." His mode of pro- gression attracted a number of boys and girls, who laughed at him, believing him to be intoxicated. He was heard to speak to them, but what he said is not known. He was also seen by two women, who told a policeman to take him away. The policeman (James Mitchell, No. 161) told me that, on finding Gow sitting at the foot of the common stair, he thought he was drunk. He spoke to him, and in reply Gow desired to be taken to his own house, at the top of the Canongate. He also said that he had completely lost his sight, and had not the perfect use of his limbs, but expressed his willingness to walk forwards, until the policeman could obtain the assistance of his comrade in the Cowgate. He was then raised up and supported by one arm, but, after moving with great difficulty past four or five shops, his legs bent under him, and he fell upon his knees. Mitchell then gave him some water to drink, which he was incapable of swallowing, and left him to get a barrow. On hi3 return he found him surrounded by women, who were pouring cold water on his head, and sprinkling his forehead. With the assistance of another policeman (James Hastie, No. Ill), he was then placed on a barrow. One of the women, Mrs. Anderson, on his being raised, saw that he made no attempt to walk, but that, as he was pulled away by the policeman, his legs were dragged or trailed after him. The second policeman, Hastie, on first seeing him, told Mitchell that it was not drink, but a fit, that was the matter with him. He lifted up his eyelids and found the eyes dull. He seemed sensible, and endeavored to say something, but could not articulate. He was now slowly conveyed to the main police-office in the High Street, where he arrived about six o'clock. Mitchell told the police-lieutenant on duty, that from the manner in which the man was lying, and from the loss of power in the legs, he now thought he was not intoxicated. At this period it would seem that, although the limbs were completely paralysed, the intelligence was still perfect, for he told the turnkey his exact address in the Canongate, in reply to a question. FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM. 461 Dr. Tait, surgeon to the police force was now sent for, and saw him about quarter past six. In reply to a note which I addressed to him on the subject, he says:— " The first impression produced on my mind from his appearance was, that he was in a state of intoxication; he was then lying on his back, with his head and shoulders elevated upon a board we have in the office for that purpose. He was sensible when I spoke to him, and tried to turn his face toward me, and slightly raised his eyelids, but appeared unable to speak. His power of motion appeared completely prostrated, for when I lifted his arm and laid it down, it lay where it was put; and when his arm- pits were tickled, he seemed to manifest a little sensibility, but could make no exertion to rid himself of the annoyance. There were occasional movements of the left leg, but they appeared rather to be spasmodic than voluntary. Several efforts were made to vomit, but these were ineffectual. His pulse and breathing were perfectly natural. He had spoken to the turnkey a few minutes before I arrived. Heat of skin natural. I visited him again, about ten minutes before seven o'clock, at which time all motion of the chest appeared to have ceased; the action of the heart was very feeble, and the coun- tenance had a cadaveric expression; pupils fixed. He was then sent to the Infirmary." He was conveyed to the Infirmary by Hastie and another policeman, M'Pherson. After being put on the stretcher, Hastie saw him draw the legs gently upwards, as if to prevent their hanging over the iron at its extremity. This was the last movement he was seen to make. On being carried into the waiting-room of the Infirmary, he was visited by the house-clerk on duty, who found him pulseless, and declared him, as> previously stated, to be dead. This was shortly after seven o'clock p.m. Seciio Cadaveris.—Sixty-three hours after death. The body was well formed and muscular. There were no external marks of vio- lence. The back and depending portions were livid from sugillation. Head.—An unusual quantity of fluid blood flowed from the scalp and longitudinal sinus when divided. There was slight serous effusion below the arachnoid membrane, and about two drachms of clear serum in the lateral ventricles. The substance of the brain was soft throughout; on section presented numerous bloody points, but was otherwise healthy. No fracture could be discovered in any part of the cranium. Chest.—There were slight adhesions between the pleurse on both sides superiorly. The apices of both lungs were strongly puckered. On the right side below the puck- ering were two cretaceous concretions, the size of peas, surrounded by chronic pneu- monia and pigmentary deposit. On the left side only induration, with hard, black, gritty particles, existed below the puckering. The structure of the lungs otherwise was healthy, although they were throughout intensely engorged with dark-red fluid blood. The heart was healthy in structure, but soft and flabby. The blood in the cavities was mostly fluid, presenting only here and there a few small grumous clots. Abdomen.—The liver was healthy; the spleen soft, readily breaking down under the fingers. The kidneys were of a brownish-red color throughout, owing to venous congestion, but healthy in structure. The stomach contained a pultaceous mass, formed of some raw green vegetable resembling parsley. Its contents weighed eleven ounces, and had an acid and slightly spirituous odor. The mucous coat was much congested, especially at its cardiac extremity. Here there were numerous extravasa- tions of dark-red blood, below the epithelium, over a space about the size of the hand. The intestines were healthy, here and there presenting patches of congestion in the mucous coat. The bladder was healthy; its inner surface much congested from venous obstruction. The Blood throughout the body was of a dark color and fluid, even in the heart and large vessels. Commentary.—From the absence of structural lesion, and the general fluidity of the blood, I was induced to suspect that the vegetable matter found in the stomach was of a poisonous nature. On examining this more minutely, it was seen to be composed chiefly of fragments of green leaves and leaf-stalks. Although much was reduced to a pulp, a con- siderable quantity of both had escaped the action of the teeth. The same afternoon, I carried as perfect a specimen of the fragments as could be found to Dr. Christison, who pointed out that they could scarcely be 462 DISEASES OF THE NERVOUS SYSTEM. anything else than the lacinim of the Conium maculatum, or common hemlock. Next day I bruised some of the leaves in a mortar, with a solution of potash, when the peculiar mousy odor of conia was evolved so strongly that Dr. Douglas Maclagan and others, although previously unacquainted with its nature, at once pronounced it to be hemlock. Dr. Christison also procured a recent specimen of the Conium maculatum from Salisbury Crags, the botanical characters of which, on being com- pared with the fragments found in the stomach, were proved to be iden- tical. No doubt could exist, therefore, that the man died from having eaten hemlock. Few cases of poisoning with this plant have hitherto been published, and none have been minutely detailed. The effects imputed to it in the notices given of prior cases are very contradictory. In some it is said to have Caused death, like opium, by stupor and coma. In others, con- vulsions of the frantic kind are symptoms stated to have been present. But the effects observed by Dr. Christison in the lower animals, in his experiments with extract of hemlock and its alkaloid conia, are totally different, viz., " palsy, first of the voluntary muscles, next of the chest, lastly of the diaphragm ; asphyxia, in short, from paralysis, without in- sensibility, and with slight occasional twitches only of the limbs." * On this account, as well as from the circumstance that considerable interest is connected with the question, as to whether the hemlock of modern times be the Ku>vetov, or state poison of the Athenians, great pains were taken to obtain a perfect history of the case. In preparing it I endeav- ored to insure accuracy, by carefully interrogating all who saw him from the time of his eating the hemlock until the period when he was brought into the Infirmary. Fortunately, he was seen by many persons, and their several accounts are, on the whole, consistent, and render the case tolerably perfect. The time of day mentioned by the different narrators shows that the poison, shortly after it was taken, produced want of power in the inferior extremities, without causing any pain. This is proved by what took place in Wright's house. His gait, which at that time was faltering afterwards became vacillating; he staggered as one drunk—at length his limbs refused to support him, and he fell. On being raised, his legs dragged after him; and lastly, when the arms were lifted, they fell like inert masses and remained immovable. Perfect paralysis of the inferior extremities was ascertained to exist one hour and a half after the poison was taken, and that of the arms half an hour later. As regards the existence of sensibility, we have only the evidence afforded by tickling the arm-pits, which, according to Dr. Tait, seemed to excite it a little. The amaurosis, however, is a proof that one nerve of sensibility, at all events, was paralysed. This seems to have happened when perfect paralysis of the inferior extremities was manifested. The excito-motory functions seemed also paralysed. Tickling the arm-pits failed in producing movements. He lost the power of degluti- tion. Dr. Tait says his efforts to vomit were ineffectual. There were no convulsions, only slight occasional movements of the left leg; and lastly, both inferior extremities were slowly drawn upwards, when placed * Treatise on Poisons, p. 885 1845. FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM. 463 over the iron of the stretcher. Three hours after taking the poison, the respiratory movements had ceased; the pupils were fixed. At this time, the heart's action was felt very feeble. These also ceased about ten minutes afterwards. The intelligence remained perfect up to a very late period. When his movements were vacillating, he was seen to direct his steps from one fixed point to another. After paralysis of the inferior extremities was fully developed, he gave accurate directions how he was to be taken home, and described his principal symptoms. Two hours after taking the hemlock, when brought into the police-office, although he could not swallow, he gave his address; and a quarter of an hour afterwards, when seen by Dr. Tait, though he could not speak, he appeared sensible, and tried to turn his face toward him. Death took place about three hours and a quarter after eating the poison, and was evidently occasioned by gradual asphyxia from paralysis of the muscles of respiration. The appearances observed in the mucous membrane of the stomach were most probably caused by the unusual fluidity of the blood, and this, in its turn, by the gradual asphyxia. The phenomena, therefore, observed in this case, fully corroborate the physiological action of hemlock, as described by Dr. Christison, from his experiments on animals.* It evidently acts upon the spinal cord, pro- ducing directly opposite effects to those occasioned by strychnia. Para- lysis of the voluntary muscles, creeping from below upwards, is the characteristic symptom, unaccompanied by pains or derangement of the intellectual faculties. Some authors have described delirium and frenzy, and others giddiness and convulsions, to have been occasioned. But such symptoms were not observed in the case of Grow, nor in the experi- ments on the lower animals by Dr. Christison. Indeed, the symptoms described by Plato in the case of Socrates, resemble as nearly as possible those which appeared in Gow. We are told that Socrates was directed by the executioner to walk about after swallowing the poison, until his limbs should grow heavy. He did so, and then lay down. On his feet and legs being squeezed, they were found insensible; they were also pointed out by the executioner to be cold and stiff. When paralysis had proceeded upwards to the abdomen, Socrates made a request to Crito, proving that his intellect was then unaffected. In a short time after, he became convulsed, his eyes were fixed, and he died. Whether stiff- ness was present in Gow's case was not ascertained. The nature of the convulsions, whether violent or otherwise, is not stated in the account by Plato, but slight spasms were observed in Gow. It will be observed, that when Socrates felt paralysis coming on he lay down. Hence the staggering and falling in the street, observed in Gow, did not take place. The description of the effects of the Kwveiov given by Nicander, however, would in this case apply with great accuracy. Ho says (I quote from Dr. Christison's paper):—" This potion carries destruction to the powers of the mind, bringing shady darkness, and makes the eyes roll. But staggering on their footsteps and tripping on the streets, they creep on their hands. Mortal stifling seizes the upper part of the neck, and obstructs the narrow passage of the throat. The * Transactions of the Royal Society of Edinburgh, vol. xiii. 464 DISEASES OF THE NERVOUS SYSTEM. extremities grow cold, the strong vessels in the limbs contract, he ceases to draw in the thin air, like one fainting, and the soul visits Pluto." If we abstract the poetical parts of the description, and remember the loss of sight, staggering and tripping in the street, the difficulty of degluti- tion, and place the loss of the intellectual faculties last, this account of Nicander agrees very well with what was observed in Gow. A difference of opinion exists as to whether the Conium maculatum of modern botanists be the Kwvetov of the ancient Greeks. Into the botanical controversy I do not feel myself qualified to enter. But, if the symptoms ascertained to have existed in the case I have related be compared with the accounts of Plato and Nicander, I cannot help think- ing that it will be found to favor the opinion of those who believe in their identity. Case XLIX.*—Poisoning with Lead—Painter's Colic—Lead Paralysis —Partial Recovery. History.—Peter Taylor, set. 50, a brewer's servant—admitted September 26th, 1851. At his occupation in the brewery he frequently uses half a hundred weight of white lead at a time, for jointing pipes, and is in the habit of painting with the same material. Twelve months ago had a severe attack of Colica Pictonum, from which he slowly recovered under medical treatment, and then resumed his work, being always subject, however, to transient twinges of pain in the bowels, as well as in the joints, which latter he attributed to rheumatism. Six weeks ago he first experienced debility and want of power in both hands, which has gradually increased since. His speech also has become slightly affected. Symptoms on Admission.—He has at present no pain anywhere, and only com- plains of want of power in both wrist joints. Both hands drop down from the arms, especially the right, which forms a right angle with the fore-arm. He can flex them voluntarily when elevated by another, but cannot raise them himself. When the metacarpal bones are supported by the hand of another, he can extend the last joints of the fingers. He has perfect command of the shoulder and elbow joints. His grasp of an object is little impaired ; there is no wasting of the extensor muscles of the arm, though they feel soft; and sensibility of the paralysed parts is normal. Bowels still somewhat constipated, but were opened freely yesterday. Speaks with unusual slow- ness, which he thinks has increased lately. All the other functions are healthy. Progress op the Case.—October ls£—Since admission the bowels have been kept open daily by small doses of the sulphate of magnesia. The arms have been put up in splints, keeping the wrist and hand extended straight out. Galvanism has been applied twice daily for several minutes in the course of the extensors, and frictions over them are occasionally employed in the interval by means of flannel cloths. October 15th.—He was ordered fy Potass. Hydriod. 3 ss; Aquce Cinnam. ; Aquae font, aa § iij. M. Sumat | j ter indies. To-day the splint was Removed from the left arm, which still droops, but is more readily extended. October 30th.—Has complained of numbness in the right arm, attributed to the bandage. The splint was, therefore, to-day,, taken off, but the hand droops as much as ever, although he can move the metacarpal joints and fingers a little better. November 10th.—There is decided improvement in the power of motion in both wrist joints, especially the left. R Extract. Nucis Vomica;, gr. vj; Confect. Rosar. q. s. utfiantpil. vj. Sumat unam ter indies. November 21st.—The pills appear to cause occasional pain in the stomach and bowels, but have occasioned no spasmodic twitches in the muscles generally. The joints have not improved since last report, but he insisted on going out. He was therefore dismissed, with the advice to exercise the wrists in pumping water. Commentary.—Lead, as a poison, appears to act first on the peri- pheral nerves of the body, and subsequently on the nervous centres, its chief manifestations being in the nerves of the intestines, causing colic, * Reported by Mr. Scott Sanderson, Clinical Clerk. FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM. 465 and those of the arms producing paralysis. Why this substance should especially affect these parts, is as much unknown as why any other poison should exert a special influence on particular portions of the nervous system. It has been recently pointed out that the metal exists in the tissues (in the form of carbonate), and sulphur consequently has been recommended internally and externally, with a view of causing its more rapid decomposition and elimination as a sulphuret. For this purpose the sulphurous mineral waters have been recommended. Common alum was given by Gendrin, and an acidulated drink made with sulphuric acid by others. Theoretically, this treatment has its difficulties; for supposing the lead to be converted into a sulphuret, how is this in its turn to be removed from the tissues, any more than the carbonate, without being first rendered soluble, and therefore poisonous? On the other hand, some physicians in France who have tried the chemical treatment exten- sively, and among others Andral, Sandras, Piorry, and Grisolle, assert that it has no influence whatever, and that patients abandoned to them- selves get well just as soon. I believe this to be the correct view; most of the primary and slighter cases getting well of themselves in hospital, in about six weeks. In most cases the disease yields to time and slow elimination of the poison from the economy. Iodide of potassium also is said by Melsens to have decomposing and eliminating powers. The latter was employed in the above case, but with no great success. Dr. Christison informs me, that " long ago, when there was a white lead manufactory in Portobello, I used constantly to have in the Infir- mary a case or two of lead colie or lead palsy and neuralgia. Every case of colic I saw got speedily well by the alternate use of opium and aperients, and every case of paralysis by generous living, stomachic ton- ics, warm baths, and especially support and regulated exercise of the arms. One man I well remember, who was three times under my care, in consequence of his always returning to the factory—had colic,, palsy, and also neuralgia; but he got well in no long time by attention to the above means." M. Duchenne has pointed out the great advantage of applying gal- vanism not generally to the arm, but more especially to the muscles affected, which in these cases are most commonly the extensores digi- torum, and not the lumbricales nor enterossei—hence why the first phalanges only cannot be extended, whilst when these are supported, the second and third phalanges can be voluntarily raised without difficulty.* * For a case of Poisoning by Aconite, see Aneurism, case of Henry Smith. 30 SECTION V. DISEASES OF THE DIGESTIVE SYSTEM. Under this head I include derangements of all those parts which are concerned in the primary digestion—that is, not only the different portions of the alimentary canal strictly so called, but the liver, pan- creas, and peritoneum. The lesions of the spleen I shall consider in the section devoted to diseases of the blood, as there can be little doubt that this, with the mesenteric and other ductless glands, is not only concerned in the formation of blood, but is most commonly disordered during its unhealthy states. DISEASES OF THE MOUTH, PHABYNX, AND (ESOPHAGUS. Case L.*—Tonsillitis. History.—Christina Slater, ast. 22, a well-nourished servant girl—admitted May 6th, 1857. Three weeks ago, after exposure to cold, during the family washing, she experienced rigors, headache, and thirst, with a sense of dryness and swelling in the throat, especially on the right side; could with difficulty swallow either solids or fluids, the latter occasionally regurgitating through the nostrils. These symptoms continued to increase till the night before admission, when she felt something give way in her throat. She spat up some matter, and thereafter felt general relief. Symptoms on Admission.—Pulse of moderate strength and frequency; no cardiac hypertrophy nor abnormal murmurs. Respirations easy and not hurried. The voice is soft and natural, but articulation is indistinct and hissing. The jaws are so im- movable as to be separable only to the extent of a quarter inch; neither by the finger therefore, nor by inspection, can the tonsils be examined; but there is tenderness on pressure, and considerable fulness in the right sub-parotidean and sub-maxillary regions. The tongue, as far as can be exposed, is covered centrally with a thick white creamy coat; the edges being of a bright red color. Can now swallow fluids; appetite returning; bowels regular. The urine is non-albuminous, slightly hyperphos- phatic, with a mucous sediment. The other functions are normal. Progress op the Case.—Poultices were applied from time to time; on May 11th, she was able to open her mouth to the full extent. Both tonsils were then seen to be enlarged, the one on the right side being the size of a walnut. Anteriorly it pre- sented two or three ulcers, with dense yellow margins, about the size of split peas. Lunar caustic is to be applied to the ulcers, and she is to use an astringent gargle. The right tonsil still continuing enlarged, was scarified May 21st, with marked relief, and diminished slightly in size afterwards, under the action of tincture of iodine applied locally. The diminution being very slow, and patient otherwise in good health, she was sent, June 8th, to Mr. Syme, who excised one half of the gland. June 10th.—Was dismissed cured. Commentary.—Hypertrophy of the tonsils is so common in young children as scarcely to demand notice, unless suspicions of croup are * Reported by Mr. W. Guy, Clinical Clerk. DISEASES OF THE MOUTH, PHARYNX, AND (ESOPHAGUS. 467 entertained, when they should invariably be examined. I have fre- quently seen the fauces almost closed from the contact of enlarged tonsils, so as to cause croup-like breathing, and give rise to great alarm. Painting them with the tincture of iodine is the best remedy, and in- cision may be practised if much permanent inconvenience be occasioned. In the above case, all the three lesions which affect the tonsils were produced—namely abscess, ulceration, and enlargement. The former burst, the two latter were treated successfully by local applications of the solid nitrate of silver, and subsequently half the gland was excised. Case LI.*—Follicular Pharyngitis. History.-r-Peter M'Donald, set. 42, a hammerman in an engine foundry—admitted December 1, 1856. Four months ago, being previously healthy, he was attacked with severe sore throat, difficulty of deglutition, and subsequently deafness in the left ear. He could not swallow sufficient food, became weak, and in a fortnight gave up work. He ascribes his attack to the sudden changes of temperature to which he was exposed. The dysphagia did not continue, but he still is weak, feels a dryness in the throat, with frequent desire to swallow his saliva, but great difficulty in so doing. Symptoms on Admission.—The voice is hoarse. On examination with a spatula, numerous red bodies, of a somewhat spherical shape, about the size of a large pin's head, are seen scattered over the mucous membrane of palate, fauces, and pharynx. The mucous membrane of the fauces and pharynx is of a deep red color; no ulcers visible; no cough; no expectoration. Digestive, respiratory, and other systems are normal. Progress of the Case.—Under local application to the pharynx with a sponge, of the nitrate of silver solution ( 3 ss of crystallized nitrate to § j of distilled water) the sense of dryness and the difficulty of swallowing saliva were relieved: his strength improved under good diet, and he was dismissed Dec. 29th. Commentary.—Pharyngitis is generally indicated by a high degree of redness, with thickening of the mucous membrane; and in certain specific forms of it, ulceration is likely to occur. For a knowledge of follicular pharyngitis, and its importance in relation to diseases of the larynx, we are indebted to Dr. Horace Green of New York. There can be no doubt that many cases of chronic cough, generally denominated bronchitis, chronic laryngitis, or clergyman's sore throat, are dependent on this lesion, and as little that they are to be cured or greatly alleviated by appropriate applications made to the part. For an account of these, however, I must refer to what is said under the head of Laryngitis. Case LH.f—Stricture of the Oesophagus from Epithelioma. History.—William Porter, set. 68, a brassfounder—admitted May 28, 1855. Two years ago a cab ran over his abdomen, across the epigastric region. He vomited a considerable quantity of blood for a few days after, and felt a pain in the back. From the pain then felt he soon recovered, and enjoyed ordinary health till four months before admission. He then for the first time experienced a sense of obstruction to the passage of food at the lower part of the gullet. The dysphagia has gradually increased, and has latterly been attended with pain. He has had no cough, and no haemoptysis. Symptoms on Admission.—Skin dry, patient greatly emaciated; pulse 68 per minute, weak and irregular; the tongue is covered with white fur. The fauces are natural; his food consists of bread or biscuit, steeped in tea, milk, or water; he does not dare to swallow more solid food. That which he takes (in the presence of * Reported by Mr. Alexander Tumbull, Clinical Clerk. f Reported by Mr. G. M. Reid, Clinical Clerk. 468 DISEASES OF THE DIGESTIVE SYSTEM. the clerk) is returned within two or three minutes. The patient believes that the food vomited has not entered the stomach ; being asked to point to the spot where he feels it stop, he puts his finger on the sternum, at the level of the fifth costal cartilage. He feels pain when the food reaches this spot. Three weeks ago, for a fortnight, the pain was felt constantly, even when no food was being taken. The smaller portion of the food, which passes the obstruction and enters the stomach, is retained with only slight uneasy sensations. There is no tumor to be detected in the epigastrium; the hepatic organ is normal in size; the abdominal walls are easily excited to rigidity. The bowels are costive; no blood has ever been passed by stool. Nervous and other systems normal. Nutrients to be taken in small quantities at a time in a liquid form often repeated. Progress of the Case.—May 4th.—Tongue clean; pulse 68, stronger than on admission. Vomiting appears to be longer delayed. May 8th.—A probang passed readily along the oesophagus to-day; there is less uneasiness, but no greater power in swallowing. May 9th.—Complains of extreme weakness; asks for beer, which is granted. May 10th.—About 2 p.m., while taking a mouthful of beer, he suddenly fell back; the mouth open; the neck stiff; .the pupils slightly contracted; the eyes turned upwards; incoherent muttering, without consciousness. His face was pale; he lay gasping for breath; there was a tracheal rale, and a fremitus was felt over the whole chest. An ineffectual attempt to vomit was followed by increased distress. He rapidly sank, and finally expired at ten minutes to three o'clock. Sectio Cadaveris.—Twenty-two hours after death. Chest.—There was a little recent soft yellowish lymph over the pleura, covering the lower part of the left lung. The subjacent pulmonary tissue felt firm, was of a dark color, and presented a granular section; it was also friable, and portions of it sank in water. About two inches above the cardiac extremity of the oesophagus there was found an epithelial ulcer, nearly encircling the tube. On slitting it up, this ulcer was seen to be of a circular form, an inch and a half in diameter. Its surface was raised about one-eighth of an inch above the level of the mucous mem- brane, and presented the appearance of a pultaceous mass, of a dirty white matter, resembling gruel. On scraping a portion of it, its base was seen to be composed of a whitish curdy matter, easily breaking down when pressed between the fingers. The muscular coat below was incorporated with the ulcer, and much thickened, so a.3 to produce a stricture of the tube, through which, however, the forefinger could be readily passed. Above the stricture the oesophagus was dilated into a pouch the size of an orange. All the other organs were healthy. Microscopic Examination.—The ulcer presented the usual structure of epithe- lioma, as described and figured pp. 212, 213. Case LIII.*—Epitheliomatous Ulceration of the Oesophagus, communi- cating with the Lung—Pneumonia terminating in Gangrene. History.—John Fraser, set. 55, a flesher—admitted September 19th, 1855. States that for five or six years previous to admission, his health had been excellent; and that he took his food without any sense of uneasiness, until three or four weeks ago. He then for the first time felt as if a ball of wind rose from his stomach to meet the food, and the food in its passage also gave him pain. The pain was gnawing and paroxysmal. During the last eleven days he has brought up his food after abortive attempts to swallow it, and for four days he has lived on gruel, not being able to swallow any solids. Symptoms on Admission.—Tongue covered with white fur; fauces natural; ap- petite reported to be good; thirst not great; food consists of gruel or bread and biscuit soaked in fluid. Says that the fluid in passing down into his stomach gives him great pain opposite a point half an inch above the lower end of ensiform carti- lage ; it is returned from the stomach in a few minutes, again causing him pain at the salne spot. He adheres constantly to this declaration. Has no nausea; never vomited blood or dark-colored matter. Abdomen is everywhere tympanitic. No tumor can be detected. Dulness of the liver normal. The bowels are very rarely opened. The pulse is 82, rather small and weak. Respiratory and other symptoms are normal. To have nutritive diet in a fluid form, in small quantities often repeated. Progress of the Case.—From September 22d to October 2d. Has been taking * Reported by Messrs. G. M. Reid and R. P. Ritchie, Clinical Clerks. DISEASES OF THE MOUTH, PHARYNX, AND (ESOPHAGUS. 469 thrice daily the following powders:—R: Bismuthi Trisnitrat. 3j; Pulv. opii, gr. ij. M. et divide in pulveres duodecem. The dysphagia continues unrelieved; the pain over ensiform cartilage is felt as formerly; and there has been also a sharp internal pain over the mammary regions. October 11th.—Describes a pain, as if his flesh were being torn away, passing from the lower dorsal vertebrae to the epigastrium. Ex- perienced temporary and partial relief from a blister applied to the epigastrium. Oct. 16th.—Ordered three ounces of sherry wine daily, and scruple doses of the hyposulphite of soda. Nov. 8th —No diminution in the pain, dysphagia, or vomiting. Ordered one drop of Fleming's tincture of aconite thrice daily. Nov. 13th.—Vomiting, pain, aid weakness continue. The aconite is discontinued, and naphtha medicinalis in ten- drop doses, with compound tinct. of cardamoms is substituted. On the 26th Nov. this mixture was also stopped, and ice was ordered. Dec. 1th.—Strong beef-tea injections per rectum are now ordered night and morning. Dec. 16th.—To-day vomited round masses looking like blood, and under microscope, blood corpuscles are recognised in them. Dec. 3d.—Blood corpuscles are found in the vomited matters to-day. Pulse small, weak, 120 per minute. Dec. 28th.—Has had hiccup for a few days past; pulse 100,, very feeble, sometimes intermitting. Thirst, which he did not feel on admission, has lately been urgent. Jan. 4th.—Has slight pain over right hypochondrium; in- creased on pressure; fine moist rales are audible over base of right lung posteriorly, with inspiration. The urine is not coagulable, but is deficient in chlorides. Jan. 5th. —Deficiency of chlorides confirmed to-day. Dulness, increased vocal resonance, and crepitation with inspiration, are detected over lower two-thirds of right lung posterior- ly. Pulse weak, small, and scarcely perceptible. To have § ij of wine additional. Jan. 1th.—Same signs as in last report. Chlorides are more abundant. Weakness extreme. Jan. 8th.—Chlorides again decreased; the pulse is more imperceptible; the skin cold; in the evening vomited three ounces of bright red blood. He died almost immediately afterwards at 9 p.m. Sectio Cadaveris.—Sixty-two hours after death. The body was much emaciated. Throat.—The larynx, pharynx, and cervical portion of oesophagus were natural. Thorax.—The heart was natural. There were a few adhesions in the left pleura, but the lung was healthy. On the right side of the chest there were firm adhesions superiorly, and on the external lateral aspect. In attempting to remove the lung a fungating growth situated over the spinal column was broken into. This growth (connected with the oesophagus) was found to have involved a portion of the tissue of the right lung near its root. On removal of the oesophagus, it was seen that a portion of it, about three inches in length, commencing a little above the root of the lun^ and going down to about an inch above the diaphragm, was converted into a fungat- ing substance of soft cheesy consistence. A part of anterior wall of the oesophagus had been broken down and removed in taking out the right lung; the whole of the internal aspect of the affected portion of the oesophagus presented a fungating ulcer- ated surface. The calibre of the tube must in consequence have been much dimin- ished. The lower end of the oesophagus, as well as the stomach and pylorus, were natural. In the stomach there were three ounces of a brownish fluid resembling coffee grounds. On removing and cutting into the right lung, a cavity about the size of a walnut was found in its posterior part, a little above the root of the lung. This cavity was filled with a brown foetid fluid, and the surrounding pulmonary tissue was softened hepatized, and broken down. Higher up were two smaller cavities, presenting similar characters, and surrounded by a layer of condensed pneumonic substance. The abdominal organs were natural. Microscqpic Examination.—The fungating mass presented all the usual appear- ances of epithelioma containing imbedded in the deeper friable portion of the growth numerous masses of concentrically arranged cells, such as are represented Fi«- 233' p. 213. n' ' Commentary.—Epithelioma of the oesophagus was present in the two cases above recorded in different degrees. In case LIL, the dis- ease was limited to a patch about one and a half inch in diameter, causing at that point a stricture of the tube, and immediately above it a considerable dilatation. From the impossibility of taking nourishment, extreme debility was induced, of which he died. In Case LIU. the 470 DISEASES OF THE DIGESTIVE SYSTEM. epithelioma was more extensive, surrounding the oesophagus internallv over a space three inches in depth, causing great thickening of the tube extending through all the coat, and even affecting the root of the right lung. The whole of the involved tissues were of the consistence of soft cheese, and^ here and there pulpy and even diffluent. It was evi- dent that at length a communication was formed between the oeso- phagus and the lung, the occurrence of which was indicated by a pneu- monia, with all the physical signs and general symptoms characteristic of that lesion. Case LIV.*—Carcinomatous Stricture of CEsophagus—Cancer of the Liver—Pulmonary Emphysema and Tubercle—Pneumonia. History.—John Currie, set. 53, a cooper—admitted 18th February, 1857. Was accustomed to drink heavily till within the last half year. Was well fed, strong, and healthy. Has had rheumatic fever thrice, the last time being twelve years ago, without any cardiac symptoms which he can remember. Had inflammation of the chest eighteen years ago. Had general dropsy nine months ago; entered the hos- pital, and was discharged cured in three weeks. It is about six months ago since the patient first experienced pain in the epigastrium after taking food, with pyrosis and anorexia. For three months he continued in this state, losing flesh and becoming weaker. Three months ago he began to vomit his food, at first in the evening, and subsequently during and after all his meals. He has vomited a little blood on three or four occasions. The character of the vomited matters is reported by him to have been as at present. Symptoms on Admission.—The tongue is clean; there is no pain nor any diffi- culty in swallowing till the food reaches a point which he indicates as beneath the lower part of the sternum and the epigastrium. He has to rest after each mouthful till the food passes this point. If it passes, he has no further pain; but the greater part does not pass, and causes him great pain till it is dislodged by vomiting. The matter vomited consists of undigested food and clear mucus. Fluids and solids are equally troublesome for him to swallow. He has often hiccup while eating, and brings up flatus with great relief. He feels a constant " working" at his stomach. There is a fulness and resistance on palpation over epigastrium; but little ten- derness, and no tumor. The area of hepatic dulness vertically below the nipple measures three inches, and laterally three and a hah". No splenic enlargement detected. No abnormality on examination of abdomen. Bowels are rather costive. The cardiac dulness at the level of the nipple is If inch. The apex is felt and dis- tinctly seen beating in the sixth intercostal space, and it is seen also in the fifth intercostal space. These two pulsations alternate, or are not exactly synchronous. At the apex, over a limited area of about one Bquare inch, a short, blowing murmur, not loud, is heard with the first sound, the second sound being healthy. At the base, both sounds are feeble, but free from abnormal murmur. The pulse is 16; irregular in rhythm. The respiratory system is normal, with the exception of a few snoring rales posteriorly. The urine is high colored, sp. gr. 1027; not albu- minous. Progress of the Case.—I took charge of this case on the 1st of May, up to which time his symptoms had continued the same, notwithstanding careful regula- tion of his diet and the administration of morphia, tr. ferri muriatis, creasote, wine, and the application of a blister. The report on May 12th is:—No improvement; pain in the epigastrium still severe. He is weaker, much emaciated, and destitute of appetite. May 30th.—Patient's diet now consists of arrowroot twice daily, beef- tea, tea and bread, and § iv of sherry wine. He is unable to take any other nourish- ment. Since admission, has been rarely out of bed. June 10th.—No change in symptoms. Continues same diet. July 1st.—For the past week the strength has gradually increased. He has been up out of bed for several days, and to-day he ventured into the green for a short time. Has some calf's foot jelly. July lQlh.— Ha3 relapsed: he now feels a constriction higher up in the oesophagus, opposite the lower part of his throat, and is unable to swallow even the little he has hitherto taken. Is greatly emaciated. Weakness extreme. July 21th.—Complains now * Reported by Messrs. J. T. Walker and W. H. Davies, Clinical Clerks. DISEASES OF THE MOUTH, PHARYNX, AND (ESOPHAGUS. 471 wholly of the constriction superiorly. Beef-tea enemata with port wine have been ordered four times a day. July 3Oth. -Enemata discontinued from the resistance of the patient. He is able to swallow wine, which he relishes. Aug. 2d— temce last report, in same state, but more feeble; lies very much on his left side; groans at intervals, his voice being comparatively strong; but articulation is very indis- tinct. Has no cough nor apparent dyspnoea. Not taken any food for four days. Aug. 3d.— Died apparently from exhaustion at 10.30 p. m. Sectio Cadaver is.— Thirty-nine hours after death. Body presented the last stage of emaciation, the abdominal wall at the umbilicus being so retracted as to be in contact with the vertebral column. Thorax___The pericardium was universally adherent; the adhesions were old and firm. The lower half of each aortic valve was thickened and almost rigid; but on trial there is no incompetence. The heart weighed nine and a half ounces, the left ventricle being slightly thinner than usual. Both lungs were emphysematous an- teriorly ; and throughout the spongy portion, indurated nodules could be felt varying in size from a coffee bean to that of a hazel nut. On section, these presented aggre- gations of miliary tubercle of a yellow color, for the most part of cheesy consistence, but here and there softened, forming purulent collections and small abscesses the size of a pea. In the left lung, the posterior third of the lower lobe presented all the characteristics of red, in one or two places passing into grey, hepatization. _ In the right lung, posteriorly, were two or three masses of red hepatization the size of a walnut. Digestive Organs.—The posterior third of the tongue presented a tuberculated appearance; the mucous membrane on section was found thick, dense, almost cartila- ginous, of greyish color, and yielding on pressure a thin greyish white juice. The mucous membrane of the pharynx was natural. In the oesophagus, an inch and a half above the bifurcation of the trachea, there existed a stricture admitting only the point of the little finger. When opened the mucous membrane appeared natural, the sub- areolar tissue somewhat thickened. Lower down, the cardiac orifice was felt exces- sively contracted, so that nothing larger than a crow's quill could be passed through it. The stricture extended along nearly two inches in length, being strictly limited to the oesophagus. The liver and stomach being removed together, a large mass of greyish-white color and firm consistence was found projecting from the posterior surface of the liver, and firmly adherent to the cardiac portion of the stomach just where the oesophagus enters it. From the surface of the liver there projected other rounded masses of greyish-white color, with central depressions, and so firm as to creak under the knife. On laying open the stricture, the mucous membrane was found not ulcerated; but in the sub-mucous tissue was deposited hard, cancerous matter, not separable by any margin from the similar substance already described as project- ing from the liver. The stomach was contracted, but otherwise healthy. Abdomen.—The kidneys felt indurated; but when examined, appeared natural. The spleen weighed only two ounces; its structure was natural. Other organs healthy. Microscopic Examination.—The cancerous masses in the liver and in the oeso- phagus contained numerous large cancer cells in all stages of development, embedded in a fibrous stroma. The tubercles in the lungs exhibited the usual appearance of miliary tubercle in various stages of disintegration, associated with pus. The red and grey hepatization was composed of an exudation in the air-cells and smaller bronchial vessels, which presented various stages of transformation into pus, being most recent in the former, and most perfect in the latter. Many of the pus cells contained fatty granules, and exhibited different degrees of disintegration. Commentary.—This man literally died of starvation, from the utter impossibility of' introducing nourishment into the system. The can- cerous mass originally formed in the liver had surrounded and com- pressed the oesophagus and cardiac orifice of the stomach, so as to reduce the canal to the size of a crow's quill, a stricture that extended through a curved line, nearly two inches long. A second stricture, but not to so great an extent, existed above this in the oesophagus. It is not sur- prising, therefore, that at last no kind of nourishment could pass these obstructions, the absence of contractile power in the diseased oesophagus 472 DISEASES OF THE DIGESTIVE SYSTEM. above being insufficient to propel even fluids through the stricture below. What appears to me, however, the most remarkable feature in this case, is the occurrence in the same individual of recent cancer, tubercle, and pneumonia. Whether the tubercle or the cancer was first formed, it becomes exceedingly difficult to determine, but certainly the nodulated groups of miliary tubercle in the lungs were in every respect similar in general appearance and structure to what is observable in phthisical cases. It is true there was no especial accumulation of tubercle at the apex of either lung, neither was there cough, nor any symptoms of pulmonary disease shown throughout the whole course of his disease. But as a decided form of exudation its presence was undoubted. The pneumonia must have come on during the latter days of his life, when he was in a state of extreme weakness. But it occasioned no active symptoms, and though conjoined with great emphysema anteriorly in both lungs, produced no dyspnoea. The pathological fact, however, of the occurrence of these three forms of exudation in one individual is, though undoubtedly rare, well calculated to demonstrate the fallacy of all exclusive views as to their production in individuals of a peculiar diathesis. Temporary dysphagia occasionally occurs in cases of hysteria or of spinal irritation, but when permanent it is always the result of organic disease of the pharynx or oesophagus. In the great majority of cases it is owing to some growth, cancerous, epitheliomatous, aneurismal, or of some other form, which, by attacking the parts themselves, induces stricture of its walls, or, by compressing them from without, causes a mechanical obstruction to the tube. In a few rare cases it has depended on pouch-like or spindle-form dilations, which, by becoming impacted with food, have caused the impediment. In all these cases, the cure will depend on the means at our disposal of removing the obstructing cause, such as external tumors compressing the part; but if it depend on disease of the pharynx or oesophagus, the treatment must be for the most part palliative. There may be a simple stricture, whieh may require surgical interference by bougies or catheters, but more generally, as observed by the physician, it is the result of cancer or epithelioma, as in the cases narrated. Under such circumstances, the treatment must be directed to support nutrition by unirritating food, given in small quantities and in a form that the patient can most easily swallow. Remedies of various kinds to alleviate or cheek the vomiting may be tried, but are seldom of permanent benefit. Very rarely an effort at healing is set up by nature, which for a time causes diminution in the more distressing symptoms, of which Case XIII. is a remarkable example. FUNCTIONAL DISORDERS OF THE STOMACH. Case LV.*—Dyspepsia. History.—James Scott, set. 51—admitted 27th September, 1852. He states that, about two months previous to admission, he experienced severe shooting pains dart ing from the left scapula to the epigastrium and left hypochondrium. For many * Reported by Mr. James D. Maclaren, Clinical Clerk. FUNCTIONAL DISORDERS OF THE STOMACH. 473 years back he has been much addicted to intemperate habits, and latterly his appe- tite for food has been considerably impaired. Symptoms on Admission.—On admission, the tongue is furred, and^ cracked in the centre; he has almost constantly a sour taste in the mouth, worse in the morning after taking food; frequent acid eructations; bad appetite, and considerable thirst. About a quarter of an hour after meals he experiences a feeling of heat and pain in the epigastrium, with acid eructations and flatulence; the latter also troubles him during the night, when the stomach is empty. These symptoms continue generally for about an hour and a half, when they gradually abate, and soon after disappear entirely. He then again takes food, and the symptoms return in about a quarter of an hour afterwards, as already noticed. He does not think that one kind of food disagrees with him more than another. He has often much nausea and loathing of food, but no vomiting. There is some tenderness on pressure at a point about the centre of the epigastrium, where he states there is always more or less pain, generally of a dull, heavy character, but sometimes occurring in sharp twinges, shooting to the left scapula, and somewhat increased on pressure. There is no unusual hardness or tumor to be felt: and there is no dulness on percussion. There i3 no tenderness or enlargement of the liver; urine normal. He is of a very desponding disposition, and does not sleep well at night. Other functions normal. R Potassm bicarbonatis 3 ij ; Tinct. Gentian. Co. % i; Infus. Gentian. Co. § v. M. ft. mist. Half a wine-glassful to be taken thrice a day. Progress of the Case.—December 31st.—Still complains of flatulence and dis; tension of the abdomen; considerable pain in the epigastrium, increased on pressure. Applicentur hirudines quatuor epigastrio et postea foveatur.' Jan. 3d.—Appetite improved; still acid eructations, with sour taste in the mouth; pain in the epigas- trium, relieved after the application of the leeches and warm fomentations. He is very desponding about his complaints, which he much exaggerates. Jan. 10th.— The sour taste and flatulence diminished; pain and uneasiness in the stomach much relieved; no tenderness on pressure; appetite much improved; no sickness or vomit- ing; bowels regular; stools natural. Dismissed in order to return to his work. The food ordered has been of a gentle, un stimulating, but nutritious kind. Commentary.—In this case derangement of digestion depended on intemperate habits, and was accompanied by excess of acidity in the stomach. The treatment was directed to counteract this condition by alkalies, vegetable bitters, and a regulated diet, which, to a certain extent, succeeded. But all such cases require exercise, regular habits, and moral control, without which medical treatment is unavailing. Case LVI*.—Dyspepsia—Oxaluria. History.—John Millar, eet. 28, a typefounder—admitted December 26th, 1852' He states that he had always enjoyed good health, with the exception of occasional palpitation of the heart, until about eight months ago. Vertigo came on suddenly when he was at work, but disappeared in a few minutes. Since then, he has had many attacks of the same kind; and of late, these have been accompanied with pain and palpitation of the heart, and tinnitus aurium. Some years ago he was much addicted to drink, but for the last four years he has been more temperate. Symptoms on Admission.—On admission, the heart was found to be healthy, and the pulse natural. The tongue was dry in the centre, moist and white at the edges, with numerous transverse fissures. He had a disagreeable taste in his mouth in the morning, and no appetite for food; had never vomited nor experienced pain in the stomach; bowels constipated. There was an anxious, haggard expression of coun- tenance, and an evident tendency to exaggerate his symptoms; he complained of ver- tigo, tinnitus aurium, and muscae volitantes. The urine, after standing some time exhibited a. slight deposit, in which numerous large crystals of oxalate of lime were visible on microscopic examination; sp. gr. 1028; otherwise normal. The other functions were normal. R Acid. nit. ; Acid, muriat. aa 3 iss; Tinct. gent. co. ? i • Infus. gent. co. % v M. A table-spoonful to be taken three times a day. Progress of the Case.—January 8th.—Since last report, the oxalates have dis- appeared, the appetite has improved, the cardiac and cerebral symptoms are removed and he is to-day dismissed cured. * Reported by Mr. James D. Maclaren, Clinical Clerk. 474 DISEASES OF THE DIGESTIVE SYSTEM. Commentary.—Dr. Golding Bird was the first to point out that oxaluria, associated with dyspepsia, was a very common disorder, and that its treatment by nitro-muriatic acid was the most successful one. The oxalic acid is probably derived from urea or uric acid, and its presence in the urine is often associated or alternates with these com- pounds. No doubt the tonic treatment practised in the above case is the best mode of relief, but here also a regulated diet, with exercise and mental occupation, are necessary to render the benefit permanent. Case LVII.*—Dyspepsia—Hypochondriasis— Oxaluria. History.—Thomas Pollock, aet. 24, hawker—admitted 25th December 1852- He says that, three years and a half ago, when stooping down in a field during a dark night to evacuate his bowels, he felt a sharp, hard body, like the stump of a shrub, penetrate his anus, causing acute pain, which continued for a fortnight, and has occasionally returned ever since. No blood passed at the time, but he has been under the care of various medical practitioners, and undergone numerous kinds of treatment. He has never had diarrhoea; but is addicted to masturbation. He has consulted the numerous works advertised in the papers on manly vigor, etc., but has derived no benefit from them. Symptoms on Admission.—On admission, tongue moist, but furred, cracked, and fissured in the centre; says he experiences a feeling of load after taking food, with occasional nausea. He has no vomiting, but an acid and sometimes disagreeable taste in the mouth; frequent flatulence and constipation, for which he is in the habit of taking aperient medicine. On placing the hand on the epigastrium, he says that there is soreness beneath the xiphoid cartilage, increased on pressure. Has occasional involuntary emissions of semen. The urine contains a slight sediment on standing, which is crowded with large and small crystals of oxalate of lime; sp. gr. 1020; otherwise normal. Sleepless at night; anxious and desponding about his complaints, which he attributes to the accident formerly mentioned, although it produced no local effects at the time, nor any structural change since. Says that he has frequent vertigo, tinnitus aurium, muscae voli- tantes, and cephalalgia. The other functions are normal. R Acid, nitrici; Acid. muriat. aa. 3 i; Tinct. gent. co. § i; Infus. gent. co. § v. M. A table-spoonful three times a day. Progress of the Case.—January 3d.—He has continued to take the acid mixture, but does not admit that he is in any way better. On the 2d, the oxalates disappeared from the urine, and were replaced by a copious deposit of amorphous lithates. Omittatur mist. acid. B^ IAquoris potassai 3 ij; Tinct. cardamom, co. § i; Infus. quassia § vii. M. Two table-spoonfuls night and morning. January 4th.—As he still continues to complain of pain in the sacral region, which he attributes to the accident, a blister, three inches by four, was ordered to be applied there. January 10th.—Since the application of the blister, the pain in the sacrum has disappeared. He expresses himself as being much better, and was now dismissed. Commentary.—In this case the presence of oxalates in the urine was associated with the same class of symptoms as in the former one, but the tendency of the patient to exaggerate his complaints was more marked. He had also a firm belief in their being caused by an accident, which possibly never happened, and even if it had, could not have occasioned his symptoms. The acid and tonic mixture removed the oxalates, but lithates took their place in the urine, which in their turn were got rid of by alkalies. Still, the fixed idea as to the cause of the disease continued, and he seemed no better. A blister was now applied to the sacrum, and he readily adopted the idea that his local complaints disappeared with the pain of the blister, and became cheerful and well. No case could better illustrate the effects of mental depression on the * Reported by Mr. William Calder, Clinical Clerk. FUNCTIONAL DISORDERS OF THE STOMACH. 475 digestive organs than this. For a period of three years he had been the subject of delusion and genital irritations, heightened by the study of those publications, which, to the disgrace of the newspaper press, are daily advertised to the people as the only means of restoring vigor to the constitution. At length, satisfied of their inefficiency, he entered the Infirmary; the error of his practices was kindly pointed out to him, nutritious diet, regular habits, and tonic treatment were obviously bene- ficial ; and fortunately his hypochondriasis yielded to the simple expe- dient of substituting real for supposed pain, and leading him to imagine that the one had cured the other. General Pathology and Treatment of Dyspepsia. By dyspepsia (from Suo-7T€Vto>, I digest with difficulty) are generally understood all those functional derangements of the stomach which are primary in their origin, that is, not dependent upon, or symptomatic of, inflammation or other disease in the economy. Such a disordered condition is exceedingly common, and often constitutes the despair of the physician, arising, as it frequently does, from causes which are obscure, or, if discovered, are beyond his control. This will become apparent by considering, in the first place, those circumstances which require to be united to secure a healthy digestion. These are—1st, A proper quantity and quality of the ingesta. 2d, Sufficient mastica- tion and insalivation. 3d, Active contractility in the muscular coat of the stomach. 4th, Proper quantity and quality of the gastric, biliary, and pancreatic fluids. 5th, A consecutive and harmonious action of the intestinal canal. Dyspepsia, or indigestion, may be produced by any cause which occasions derangement of one' or more of these conditions; and hence it is why so many different circumstances may produce some- what similar symptoms, and why so many different remedies have been found effectual in various cases. Notwithstanding that you will fre- quently meet with instances which baffle all preconceived rules, there can be no doubt that a careful attention to the essential physiological conditions above enumerated will, in a great majority of cases, conduct you to a successful rational treatment. Thus— 1. Of all the causes of dyspepsia, excesses in eating and drinking are the most common. An over-extended stomach, or too rich a meal, not unfrequently induces a feeling of weight or fulness in the epigastrium, nausea and eructation of acid, bilious, or gaseous matters, with a loaded tongue, headache, and other general symptoms. This is acute dyspepsia, or the embarras gastrique of the French. Occasionally, there is more or less vomiting of bilious matter, when the attack is vulgarly called a bilious seizure. If called to see such a case, immediately on its occur- rence, and before the ingesta have left the stomach, as determined by the sense of load at the epigastrium and by percussion, an emetic should be given; and if vomiting is about to occur, it should be assisted by warm diluents. As soon as the stomach is quieted, or, if you have been called in at a late period, when the ingesta have passed into the intestines, a purgative should be administered, consisting of four grains of calome 476 DISEASES OF THE DIGESTIVE SYSTEM. with four of compound extract of colocynth, followed in a few hours by a draught of salts and senna. If necessary also an enema may be given. The purging, with a day or two's confinement to farinaceous food, will generally get rid of such an attack; but their frequent repetition leads to the chronic form of dyspepsia, in which careful regulation of the diet, with exercise, must constitute the chief treatment. Hence the advantage of what is called " change of air," and much of the benefit which ia derived from watering places. Chronic dyspepsia, however, is far more commonly caused by excess of spirituous and vinous drinks, than by eating; and, in such cases, abandonment of the evil habit is a sine qua non in the treatment. Tea-drinkers are very liable to the disease, and its frequency among female servants is probably owing to over-indul- gence in this beverage. 2. It may frequently be noticed, that those who have acquired the habit of eating rapidly are more or less dyspeptic. I knew a journey- man printer, who had been much tormented with indigestion, but who was cured by changing his residence. The reason of this cure was for some time a mystery; on again changing his house, the disease returned; still no apparent cause could be discovered. I ascertained, at length, that it depended not on the locality per se, but on its distance from the printing-house. When far off he ate his dinner with his family rapidly, having only just time enough to walk home and back within the hour. When he lived near, the time otherwise spent in walking was occupied in eating, or in cheerful converse with his wife and family. Since I made this observation, it has often occurred to me that the distance of the residences of artizans from their place of employment may be the occasional cause of the dyspeptic symptoms they frequently suffer from. The exact object of the saliva in the process of digestion, whether it be to convert the farinaceous compounds of the food into glucose, or by its viscidity to mix up air with the portions swallowed, is not positively determined; but its necessity for digestion is shown by what happens in cases where the under lip has been lost by accident or disease, or where salivary fistulae have formed; in such cases dyspepsia is generally present, and in some the disordered digestion has been cured by opera- tions that, by restoring the parts to their normal condition, prevent the escape of saliva. Again, persons habituated to the dirty habit of spit- ting, are for the most part dyspeptic. In all cases where dyspepsia can be traced to this source, the treatment becomes obvious. 3. The contractile movements of the stomach, which, by kneading the ingesta, and keeping them in constant motion, secure their intimate admixture with the gastric juice, and the rapid transference to the duodenum of such portions of it as are transformed into chyme, are evidently of great importance to the proper performance of digestion. The experiments of physiologists have shown that digestion goes on in gastric juice taken out of the stomach much slower than in the stomach, and that section of the pneumogastric nerves, by arresting the contrac- tile movements, permits only the circumference of the mass in contact with the secreting surface to be digested. These facts at once explain FUNCTIONAL DISORDERS OF THE STOMACH. 477 the well-known influence of mental emotions upon the stomach. Con- tentment and hope are as favorable, as dissatisfaction and despondency are injurious, to good digestion. Nothing is more common than dys- pepsia among literary men who overtask their mental faculties; among young persons of very excitable minds; and among individuals of a melancholy temperament, hypochondriacs, etc. etc. It is in such cases that cheerful society, active and appropriate occupations, change of scene, removal from mercantile or literary employments, variety in trains of thought, and so on, are beneficial. Hence also many of the good effects of travel, visits to watering-places, etc. etc. 4. Our knowledge with regard to the offices performed by the gastric, biliary, and pancreatic juices in the digestion has of late years been much advanced. Thus, the gastric juice operates more especially on the al- buminous, and the pancreatic juice on the fatty compounds of the food. The function of the bile is more obscure; it probably acts as a means of precipitating or separating some of the excretory matters from chyme, and so facilitates assimilation of the nutritive portions. Digestion may be deranged by all those causes which increase or diminish too much the secretion of these three fluids. Thus, excess of acidity in the stomach is one of the most common causes of dyspepsia, and is associated with that form of it which accompanies scrofulous and tubercular diseases. It may be in such excess as to neutralise the alkaline action of the pancreatic juice, and render it incapable of emulsionising fatty matters. In such cases the alkalies, with bitter tonics and the direct introduction of animal oils in excess, are indicated. On the other hand, the gastric juice may be diminished in quantity, as frequently occurs in persons who suddenly overtask the powers of the stomach at feasts, or in old persons with feeble digestion. The sense of load after eating is generally indicative of slow digestion from this cause. In acute cases, a stimulant rouses the stomach to increased action, and hence the moderate use of drams and generous wines after dinner is occasionally useful. In old persons the sense of load and feebleness is best removed by giving up tea, and drink- ing at night a little weak brandy and water. In chronic cases, acids are indicated, especially muriatic acid. The Tr. Ferri co. of the pharma- copoeia is a useful preparation in chlorotic females. The prepared gastric juice of the calf has been lately recommended as a remedy in this case; and is undoubtedly in some cases of much service. We have no distinct means, as far as I am aware, of rousing the pancreas into action, and yet many cases are on record in which fatty matters have passed undigested through the alimentary canal in conse- quence of obstruction to the pancreatic duct. In such cases, and in all those in which fatty matters are difficult to digest, alkalies, especially the sodce bicarb with vegetable tonics, are indicated. When the bile is deficient, constipation and dyspepsia are usual re- sults, and are to be relieved by gentle mercurial purgatives, with extract of taraxacum, and by remedies, such as rhubarb, and especially the com- pound rhubarb pill, which, by acting on the duodenum, also favor the flow of bile into the upper part of the alimentary canal. Dr. Clay, of Manchester, has recommended in such cases the administration of ox- gall, a remedy, which, although not extensively given, is evidently 478 DISEASES OF THE DIGESTIVE SYSTEM. rational, and calculated by its purgative action to be highly serviceable. Excess of bile, on the other hand, ought to be treated by drastic purgatives, diuretics, and diaphoretics, according to circumstances, to cause excess of excretion. Exercise should also be insisted on to call the lungs into action, and thus relieve the liver in its office of separating hydrocarbon. 5. A derangement of the consecutive and harmonious action of the alimentary canal is another frequent cause of dyspepsia, for it is as neces- sary that those portions of the food which are not assimilable should be removed out of the economy, as that the nutritive materials should be absorbed. Hence, whatever impedes the contractility of the intestinal canal, whatever alters the structure of its mucous membrane, or what- ever mechanically obstructs its calibre, induces dyspeptic symptoms. The removal of these various conditions, whether by stimulating the nervous centres by appropriate diet, or by purgatives and astringents, need not be more particularly dwelt upon here. I would only observe that the constant use of laxatives, however they may temporarily relieve, cannot cure, and that in all chronic cases a proper action of the bowels must be obtained as much as possible by means of dietetic and hygienic regulations. In many cases of dyspepsia, two or more of these classes of causes may be combined so as to render the indications for treatment complex and apparently contradictory. In other cases, one or more causes may exist, although from the indications present their nature cannot be deter- mined ; in such cases, our treatment must always be more or less vague and unsatisfactory. Lastly, there are a few instances where dyspepsia can only be explained by idiosyncrasy, in which we find this or that particular article of diet to derange the digestive function, and in which avoidance of the offending cause is the only plan of treatment that is at- tended with success. In addition to the different kinds of dyspepsia to which I have directed your attention, it is practically important to keep in remem- brance the leading symptoms which may be present, and the remedies by which they may be removed. The symptoms are anorexia, acid eructa- tions, sense of load at the stomach, cardialgia, vomiting, flatulence, pal- pitations of the heart, and cephalalgia. Some persons talk of a stomach cough, but this is more commonly dependent on sources of irritation in the oesophagus or pharynx, which have hitherto been overlooked. I have already alluded to the mode of treating most of these symptoms. Pal- pitations of the heart often occasion alarm in young dyspeptic persons; and in such cases, besides remedies directed towards the stomach, change of scene, removing attention from the affected organ, and varied reading should be enjoined. The sense of load in the stomach is most fre- quently removed, as I have previously said, by acids; and sour eructa- tions and cardialgia are best relieved by alkalies and bitter tonics. Vomiting and flatulence are often very troublesome symptoms. The varied remedies which may be employed in a case of chronic vomiting may be gathered from the following history :— Case LVIII.*—Dyspepsia—Vomiting of fermented matter containing Sarcince. History.—Thomas Spence, set. 53, a weaver—admitted September 6, 1852. * Reported by Mr. William Calder, Clinical Clerk. FUNCTIONAL DISORDERS OF THE STOMACH. 479 He states that for fourteen or fifteen years past he has been subject to occasional vomiting, which generally occurred on Sundays, owing, he supposes, to want of exercise at his usual emplovment. On these days he scarcely ever took his meals from fear of the almost certain vomiting which would follow. For two or three years past he has been liable to frequent heartburn, water-brash, and acid eructa- tions, but was able to continue at his usual employment till about six months ago. Since then, he has been gradually losing his appetite, and his strength has become much prostrated. He has never vomited blood or any dark-colored matter, and has never passed any such by stool. Symptoms on Admission.—On admission, tongue clean; no difficulty in degluti tion; appetite capricious, but always best in the morning and early part of the day. Shortly after taking food, he begins to have uneasy sensations in the epigastrium, sickness, and a sense of weight at the stomach. When these symptoms appear, the abdomen generally begins to swell, and in about an hour to an hour and a half the food is vomited. The rejected matters consist generally of the half-digested food, with a thick, dirty, frothy scum on the surface, resembling yeast. He has also frequent pyrosis, acid eructations, and flatulence, the latter sometimes so great as to occasion a sensation of choking, especially after vomiting. These symptoms are worse after some kinds of food than others: oatmeal, especially in the form of porridge, produces them in the severest form; broths, vegetables, or any kind of slops, disagree with him; animal food suits him best, but when even this is taken for any length of time, the symptoms soon reappear. The abdomen at present is much swollen, very tense, and tympanitic on percussion, with consider- able tenderness over the epigastrium. The bowels are generally constipated ; the stools usually of a dark color and hard consistence. He has occasionally slight pain and difficulty in voiding his urine, which is slightly phosphatic. Other functions are normal. Progress op the Case.—On taking charge of this patient on the 1st of November, I found him vomiting from time to time large quantities of fluid mixed with undi- gested matters, on which there gathered, after a short time, a thick brownish scum, exactly resembling yeast. On examining this scum with the microscope, it was ascertained to contain a large number of sarcinae ventriculi (see p. 98, Fig. 88), mingled with starch corpuscles, more or less broken down, and granular matter. From the ward-books I learnt that his treatment had consisted in the successive administration of—1. The local application of leeches; 2. Of the sulphite of soda, in scruple doses, with two grains of aromatic powder three times a day; 3. Of half a grain of protochloride of mercury at night; 4. Of a scruple of the sulphite of soda every three hours, which was subsequently increased to half a drachm; 5. Of creasote mixture; 6. Of a naphtha mixture; 1. Of bismuth and aromatic powders; and 8. Of pills of calomel and opium. These different kinds of treatment, some of which, especially that of the sulphite of soda, had been continued for several weeks without intermission, seemed to have produced no good effect. November 11th.— During the last four days, he has vomited every night, four hours after dinner, that is, about six p.m. The ejected matter presents the same yeast-like character formerly described; but the sarcinae, though still abundant, are not so numerous. He complains of a great sense of distension, and a feeling of "working" or "bubbling" in the stomach shortly before vomiting. R Acid. Hydrocyan. dU. m. xviij; Syrup. Aurant. |j. Aquce ? v. M., half an oz. three times a day. November 20th.—The hydrocyanic acid checked the vomiting till last night, when it returned with more violence than ever. November 24th.—Vomiting still continues regularly every day. Omittatur Mist. Acid. Hydrocyan. fy Liquor. Potass. § ss; Aqum § vss. Two table- spoonfuls to be taken every four hours. December 2d.—Alkaline mixtures again checked the vomiting, which, however, returned last night to a slight degree. Applicet Vesicat. 4x5 Epigastrio. December 8th.—Vomiting has once more returned daily since last report. R Tinct. Ferri Muriat. § i. Sumat 3 ss ter in die ex aqud. December 16th.—The vomiting has been again checked, but once more returned in a slight degree at one a.m. this morning. The matter ejected exhibits very little of the usual frothy scum, but consists of a brown liquid like coffee, with a few shreds of undigested food. It is of intensely acid re-action, and contains only a few sarcinae. The dose of the Acid Tincture has been reduced to M. xv. The diet during this period has been principally animal, porridge and vegetables invariably increasing his 480 DISEASES OF THE DIGESTIVE SYSTEM. complaint. To-day he left the hospital to visit his friends in the country, expressing himself as greatly relieved. Commentary.—The kind of chronic vomiting and dyspepsia here spoken of has been long known in Scotland, and was described by Cullen as a form of pyrosis. It was supposed to be associated with the habit of largely consuming oatmeal as a principal part of the diet; but its real pathology was unknown. In 1843 Mr. Goodsir discovered in the ejected matter from the stomach, in a case of this kind, organized forms, which, from their resembling a wool-pack, he denominated sarcina. He considered that they were of a vegetable nature, and by multiplying fissiparously, gave to the contents of the stomach the appearance of yeast, which is also known to be dependent on the development and growth of vegetable structures. The occurrence of these sarcinae in the stomach of course explains their frequent presence in the faeces, although, whether they are ever developed in the intestines is unknown. In two cases I have seen them in the urine, when they were uniformly smaller in size than the sarcina ventriculi. They have also been discovered by Virchow in an abscess of the lung; and I have seen them in the juice squeezed from an cedematous lung. Dr. Tilbury Fox has found them on the skin. The origin and exact mode of development of these struc- tures are unknown; but their presence is no doubt the real cause of the chronic vomiting and other symptoms of the individual affected; and the cure of the disease will depend on the use of such means as are capable of insuring their destruction and preventing their return. It is obvious, however, that the means which destroy or check vegetable growths on the external surface of the body (see Favus), are not applicable to the mucous lining of the stomach. Besides, we do not know whether these parasites grow in an exudation poured out on the mucous membrane, or are developed only in a fluid. Again, it is very possible that, on being introduced from without, the conditions necessary for their development may be dependent on particular kinds of ingesta—a view which derives support from the facts observed in the case before us, namely, that the sarcinae were always increased by farina- ceous kinds of food. On all these points, however, we are as yet igno- rant, and our efforts at cure hitherto have not so much been directed to cutting off the sources of growth, as to destroying the sarcinae after it has proceeded to a certain extent. With this view it has been imagined, that the sulphite of soda would destroy them, by causing, on its union with the gastric juice, the extrication of sulphurous acid, which is so destructive to vegetable life. This remedy has consequently been given, and not unfrequently with success; but in the present case it was of no benefit. Subsequently a variety of medicines were administered, several of which succeeded in checking the vomiting for a time. Indeed, it was remarked that the mere circumstance of changing the medicine was sufficient to stop the vomiting for several days, when it returned and continued as before. Of all the numerous remedies tried, the Tr. Ferri Muriatis seems to have done most good. The following case offers a re- markable contrast to the one just given, for although of some standing it was rapidly cured by the sulphite of soda. FUNCTIONAL DISORDERS OF THE STOMACH. 481 Case LIX*—Dyspepsia—Vomiting of fermented matter containing Sarcina. History.—Christina Torrence, aet. 18, servant—admitted July 11, 1853. For the last three years has been suffering from more or less pain in the stomach, loss of appetite, and occasional vomiting, generally soon after meals. The ejected matters have always been very acid, and have varied in appearance with that of the food taken, which, for the most part, consisted of tea and porridge, with very little animal food. She is thin, and her general strength has been much reduced. She has taken all kinds of medicines, and has been treated homceopathically for some time without the slightest relief. Progress of the Case.—On admission she was ordered bismuth and aromatic powders, which sUghtly alleviated some of the symptoms. On the 14th, however, there was vomiting of a brown frothy fluid, to the extent of § iv, which, on micro- scopic examination, was demonstrated to contain numerous sarcina?. A scruple of Sulphite of Soda was ordered to be taken three times a day. On the 22d, vomiting again returned, but the rejected fluid contained no sarcinae. From this time all pains ceased, other symptoms disappeared, and she was dismissed quite well July 28th. Commentary.—Although it occasionally happens, as in the above case, that a cure may be rapidly accomplished, this is not to be hoped for when the disease is very chronic. In addition to what has been said on this subject, I may add, that whenever everything has been tried and failed, I have recently found that complete abstinence from food for one or two days, while the body is supported by nutritive enemata, has checked the vomiting and accumulation of fluid; that full doses of opium, the stomach being empty, will still further diminish irritation; and lastly, that I have caused great relief and prevented vomiting and much exhaustion, by removing the fluid from the distending stomach with a stomach-pump, instead of allowing it to proceed to such a point as to occasion much pain. ORGANIC DISEASES OF THE STOMACH. Case LX.t—Chronic Ulcer of the Stomach—Recdvery. History.—Janet Grant, aet. 30, married—admitted 14th November, 1852. She stated that she enjoyed tolerably good health till twelve months ago, when she had an attack of haematemesis, which returned on three successive days early in the morning. The vomiting was preceded by a sense of weight and uneasiness in the epigastrium, nausea, dimness of sight, and feeling of syncope, which actually occurred on one or two occasions. After vomiting took place, she generally suffered from severe griping pains in the bowels until they were opened. The stools were often of a dark brown color. The quantity of matters ejected from the stomach varied from one to two pints, and contained coagula of blood. She has been twice received into the Infirmary, and on both occasions dismissed much relieved. After January, 1852, she continued in good health, and was able to follow her usual occupa- tion until the 3d of November, 1852, when the hcematemesis returned, havin" been preceded by the symptoms already enumerated. On this occasion there was less blood than formerly; but the vomited matter still contained numerous bloody coagula. She had no recurrence of vomiting for eight days, but remained very weak and was confined to bed. On the 11th November she passed by stool some matters like slimy tar. Since then she has frequently vomited, sometimes as often as three hl"nnr),lr Ti.me3 -a day' a (luantity of matter consisting principally of dark-colored mooa. ine pain in the head, epigastrium, and between the scapula;, has increased since that time. badST^°^3 °-N tADMiSSI01f-—On admission, tongue moist, slightly loaded; appetite oaa, tood is rejected from the stomach almost immediately after being taken -pain * Reported by Mr. Joseph Johnston, Clinical Clerk. 31 f Reported by Mr. F. M. Russell, Clinical Clerk. 482 DISEASES OF THE DIGESTIVE SYSTEM. and tenderness in the epigastrium on pressure; slight tenderness over the whole abdomen, which becomes much distended after taking food. Bowels rather costive • no blood in the stools at present, and no blood corpuscles in the vomited matters when examined by the microscope. Urine normal. Other functions normal. R Sulph. Magnes. § ss; Acid. Sulph. dil. 3 i; Infus. Rosarum § viij. Sumant. § ij et repetant. eras mane. IJ Acid. Gallic. 3 i; Pulv. Opii gr. iij. M. et divide in pulv. xij. Sumat unum ter in die. Progress of the Case.—November 15th.—Had some vomiting to-day, but no blood. Still considerable pain in the epigastrium. Bowels freely moved by medicine • stools very dark in color. Nov. 11th.— Omitt. Acid. Gallic. R Bismuthialbi 3 ss • Pulv. Opii. gr. iss. M. et div. in pulv. vj. Sumat unum ter in die. Farinaceous diet. Nov. 18th.—Complains of burning pain at lower part of the sternum; former pain in epigastrium somewhat easier; no vomiting since the 16th; bowels open; stools still of a dark color; great thirst; tongue loaded and coated with brown fur in centre; with bad taste in the mouth. Nov. 20th.—Still considerable pain and tenderness in epigastrium, which is now referred to one spot about the size of a crown-piece; bowels confined; pulse 15, natural. Applicentur hirudines iv epigas- trio, Repetat. mist, cathartic, si opus sit. Nov. 23d.—Complains still of pain in epigastrium, which was slightly relieved by the leeches; has had no return of vomit- ing ; bowels open. Applicet. Vesical. (3 x 2) epigaslrio. Nov. 26th.—Pain in epi- gastrium considerably relieved since the application of the blister. Still bad appetite and sour taste in mouth. R Garb. Potass. § i. Div. in pulv. xij ; sumat unum ter in die. Dec. 9th.—Pain in epigastrium much relieved, and only returns at intervals, and in much less degree than formerly. She now takes her food well; bad taste in mouth gone; bowels still costive; pulse 80, of good strength. Dec. 11th.—Her former stomach symptoms have entirely disappeared. Dismissed. Commentary.—The vomiting excited on taking food, the haema- temesis, and the local pain increased at the epigastrium on pressure, in- dicated the presence of an ulcer in the stomach, which, by opening blood- vessels, had several times caused extravasations of blood. Before I saw her, an astringent mixture, with gallic acid, had been ordered to check the tendency to hemorrhage. For this I substituted quietude, a farinaceous diet, to be taken in small quantities at a time, frequently repeated, and powders of white bismuth and opium, to check acidity and relieve pain. The pain not subsiding, six leeches were ordered to the epigastrium, fol- lowed by warm fomentations, and subsequently a blister was applied there, the result of which treatment was gradual abatement, and at length complete disappearance of all her symptoms. Case LXL*—Chronic Ulcer of the Stomach—Cure. History.—Mary Reid, set. 38, married—admitted December 20th, 1852. She states that about four years ago, having been exposed to cold and wet, she was seized with shivering, followed by severe pains in the epigastrium, with uneasy sensations in the lower part of the abdomen, resembling labor pains; these were accompanied by thirst, loss of appetite, sickness, and vomiting. These symptoms disappeared, but re-occurred at intervals up to December, 1851, when she had a more severe attack than before, and since then she has always been complaining more or less of the same thing. ^ About three months ago, she felt as if something gave way in the left hypo- chondrium, and nearly fainted. She immediately afterwards vomited about a tea- cupful of blood; this took place four or five times during the night; but the last time the ejected matters were paler and more watery, having somewhat the appear- ance of finely-grated carrots. The loss of appetite, thirst, pain in epigastrium and bowels, with frequent severe headache, have continued up to the present time. She has had no return of the haematemesis, but generally vomits her food about half an hour after it has been taken. Symptoms on Admission.—On admission, she has a pale anaemic appearance. The tongue is furred, appetite bad, pain in epigastrium and distension, with a sense * Reported by Mr. F. S. B- F. de Chaumont, Clinical Clerk. ORGANIC DISEASES OF THE STOMACH. 483 of load at the stomach after meals, which continues till relief is afforded by vomiting, which comes on generally in about half an hour. She complains also of pain in the left hypochondrium; has no uneasy sensations in the bowels, but habitual costive- ness, for which she has been in the habit of taking laxative medicine. She has been much troubled with palpitation, but the heart sounds and impulse are normal; pulse 96, small, and rather soft; micturition normal; urine of a pale color, sp. gr. 1022, with slight deposit, showing phosphates under the microscope. Catamenia now present. She does not sleep well, has slight headache and occasional vertigo, with muscae volitantes, pain in lumbar region, but no tenderness over spine. Other functions normal. To remain quiet in bed. Farinaceous diet in small quantities. To have the bowels gently opened. Progress of the Case.—December 23d.—Bowels moved since last report; com- plains of much pain in the epigastrium; has had no vomiting of blood since admis- sion. Applicent. hirudines iv part, dolent. et postea foveatur. Omitt. alia. R Lactis Recent. § xii; Aq. Calcis J vj M. To be taken as a drink when thirsty. Dec. 30th.— Continues somewhat easier; complains still of occasional pain in stomach; ^appetite rather improved; less thirst. Bowels very costive. Jan. 4th.—Complains still of severe pain in epigastrium, with nausea, but no vomiting. Tongue rather furred. It has been found that the patient has been getting up and walking about after the visit, and has taken some beaf-steak, contrary to orders. R Pulv. Scammon. et Pulv. Jalap, aa gr. x. M. Ft. pulv. hora somni sumend. Jan. 6th.—Bowels well opened, tongue much cleaner, feels better, and slept well during the night. To have rice diet. Has been complaining again of pain in stomach; tongue furred, but moist; appetite rather better; slept well during the night; bowels open. Jan. 9th.— Has been rather sick to-day, and vomited a little during the night for the first time since admission. She still complains of pain in epigastrium. Applicet. Vesical. (3 x 2) part, dolent. Jan. 12th.—Has been much relieved since the application of the blister, and expresses herself as feeling a great deal better. Tongue moist, and cleaner than be- fore ; less thirst; appetite improved; bowels still costive. Jan. 20lh.—Dismissed cured. Commentary.—This case in all its essential features is very similar to the former one, with the exception that vomiting, instead of occurring immediately after taking food, came on half an hour later. The same treatment was pursued, but was not so carefully followed out, for it was ascertained that she was continually getting out of bed, and committing indiscretions, which caused returns of the symptoms. Case LXIL*—Chronic Ulceration and Perforation of the Stomach—Perito- nitis—Limited Pneumonia with Ganyrene—Abdominal Abscees, simu- lating Pleurisy—Death. History.—Evina Clark, aet. 29, single, housemaid—admitted December 1, 1852. From the age of fifteen, she had more or less derangement of the functions of the stomach, as exhibited by frequent vomiting of greenish matters, not preceded by any nausea. She attributes her complaint to a severe stomach disease at the age of fifteen which confined her to bed for some months. Two months ago the vomitings became more frequent, and have continued worse than usual ever since. She has been in the habit of taking very large quantities of bicarbonate of soda, sometimes even as much as 1 oz. per day. On the day before admission, she took a dose of castor-oil and this morning (Dec. 1) she rose at five o'clock to stool, then returned to bed. At half-past five, she again rose to see what o'clock it was and again returned to bed and fell asleep without having experienced any pain. About six o'clock she awoke'with severe pain in the epigastrium, and a feeling of faintness. Her mistress, on being summoned to her bedside, administered to her half a glass of brandy in some hot water. Immediately after this was swallowed the former pain became excruciating; the abdomen was then fomented with hot water, and medical assistance sent for. The medical man ordered warm bran poultices to be applied, which somewhat relieved the symptoms; three hours afterwards, the pain again becoming violent, one drachm of tincture of opium was administered, and she was sent to the Infirmary. The cata- menia have always been regular. * Reported by Mr. F. S. B. F. de Chaumont, Clinical Clerk. 484 DISEASES OF THE DIGESTIVE SYSTEM. Symptoms on Admission.—On admission she was in a state of extreme depression the surface cold, face livid, pulse 108, almost imperceptible; and the house-clerk administered a draught, which was at hand, composed of Sp. Ammon. Aromat. min. x; Sp. JEther. Sulph. min. xv; Sol. Mur. Morph. min. xx; Aquee § ss. Warm fomentations to the epigastrium were also ordered. When first seen at the hour of visit, she complained of intense pain in the abdomen, especially in the epigastrium and left hypochondrium, which was increased by pressure. The tongue was slightly furred in the centre, but moist. She had great thirst, no nausea; bowels had been freely opened at five o'clock in the morning. Heart sounds normal; pulse 136, the strength having much improved since the draught, which caused no increase of the pain. Is evidently under the influence of opium. All the other functions are nor- mally performed. To have immediately an enema of beef-tea with an ounce of brandy. The warm fomentations to be continued. Progress of the Case.—In the evening the pain was diminished to a feeling of soreness; pulse 129, small; lividity of face and depression continued; surface cold; np rigors. Has had, at intervals of three hours, four enemata of beef-tea, with an egg, two containing an ounce of brandy, and two with one drachm of laudanum. She has also been sucking ice to relieve her thirst. December 8th.—There has been profuse sweating during the night; face is still pale; pulse 126, weak and thready; acute pain continues on pressure below ensiform cartilage. The abdomen is tense and tympanitic, but the tenderness is slight; considerable flatulence in stomach; febrile symptoms well pronounced. R Bismulhi albi gr. xviii; Pulv. Opii gr. iii. M. fiant pil. vi. One to be taken every six hours. The nutritive and anodyne enemata to be continued. Dec. 9th.—She vomited yesterday afternoon, 3 p.m., about a pint of green fluid, and at the same time passed a fluid faeculent stool. Slept a little during the night. To-day she is somewhat refreshed, but the symptoms are the same as yesterday. Dec. 10th.—Yesterday evening, the epigastric pain having increased, and extended into left hypochondrium, six leeches were applied, followed by warm fo- mentations. To-day pain and tenderness continue ; pulse 120 ; improved in strength. Six more leeches to be applied. The anodyne and nutritive enemata to be continued. To suck ice to relieve the thirst. Dec. 11th.—Bowels were open shortly before the visit; pulse 128, full; tongue dry; thirst continues; but appetite is returning. Tender- ness of epigastrium and abdomen has nearly disappeared. To have beef-tea, by the mouth, in table-spoonfuls at a time, and occasionally toast and water to relieve the thirst. Dec. 12th.—The beef-tea produced a disagreeable but not painful sensation in the stomach, but there has been no vomiting. Pulse to-day 128, of good strength; feels much easier, and can turn herself more freely in bed. There have been two faecal evacuations since yesterday. Dec. 13th.—She has no pain; pulse 128, of mode- rate strength. To have a Utile toasted bread soaked in beef-tea. Dec. 14th.—The toast and beef-tea occasioned uneasiness and tightness in the epigastrium and both hypochondria, followed by dyspnoea and general restlessness, but no pain. The bowels were opened twice during the afternoon and evening. To-day there is tenderness over the right hypochondrium; febrile symptoms have again returned; pulse 132, rather feeble. Six leeches to be applied over the tender part. To have enemata of brandy and beef-tea every two hours. To suspend the administration of food by the mouth. Dec. 15th.—At the evening visit yesterday the febrile symptoms had greatly increased; thirst excessive; tongue dry and cracked; abdominal tenderness much relieved by the application of the leeches. To-day the febrile symptoms continue; face is flushed; and, on being interrogated, she states that she had a rigor and feeling of cold yester- day afternoon. On percussing the chest posteriorly, there is dulness over lower third of right lung, with double friction murmur and segophonic vocal resonance; on the left side also slight dulness inferiorly, with crepitation, during inspirations, pulse 132, feeble. The enemata, which have been continued at intervals, are no longer retained. Intermittantur enemata. To have a little calfs-foot jelly by the mouth, alternated with a table-spoonful of clear brown soup every two hours. R Solutionu tartratis antimonii 3 iij ; Potassat acetatis 3 ij ; Sp. cetheris nitrici 3 v 5 aqua! § v. M. Fiat mislura. A table-spoonful every four hours in two or three table-spoon- fuls of water. Dec. 16th.—Yesterday evening there was great exhaustion and feebleness; the mixture was suspended: and a table-spoonful of wine was ordered every two hours. To-day no tenderness over abdomen, but the dyspnoea and the physical thoracic signs continue; febrile symptoms still strongly marked; pulse 140, soft and vibrating; there is much flatulence. At her own request, she was allowed ORGANIC DISEASES OF THE STOMACH. 485 fifteen grains of the bi-carbonate of soda. To continue the jelly and brown soup, with half an ounce of sherry every hour. Dec. 11th.—Feels better to-day; urine loaded with lithates; flatulence has been relieved by the bicarbonate ot soda. Dec. 18th.—No change. To have milk and lime-water to drink. Dec. 19th.—Com- plains of increased pain in inferior portion of right side of chest, where there is still dulness and loud friction. Some dyspnoea. Six leeches to be applied. Dec. 20th. Pain was relieved by the leeches, but the dyspnoea and physical signs on both sides of chest continue. Blister 4 by 3 to be applied over lower portion of right lung posteriori!/. Dec. 21st— Has had copious sweating during the night; otherwise the same. Dec. 22d.—Much weaker; pulse 136, small and weak; lithates have disappear- ed from the urine; great dyspnoea. R Sp. JEth. Nit. § ss; Tinct. Colchici 3 ij; Aquae § v; a table-spoonful every four hours. To have an enema of beef tea and egg ; and rice, with beef-tea, by the mouth. Dec. 23d.—Is free from pain ; general symp- toms unchanged; pulse 124, weak; slight subsultus tendinum; appetite capricious; prefers arrow-root to rice. Dec. 25th.—Complains now of diarrhoea. Habeat enema c. Tr. Opii min. xl. Dec. 26th.—Diarrhoea continues; early this morning took the fol- lowing draught:—R Sol. Mur. Morph. m. xv; Tinct. Catechu 3 ss; Syrup. Idmonum 3 j At. No change in the febrile symptoms, dyspnoea, or the pulmonary physical signs; has no pain; pulse 124, weak; skin clammy; states that she felt very cold during the night. Dec. 21th.—Diarrhoea continues. To have an enema of starch and opium. Dec. 28th.—Diarrhoea has ceased; dyspnoea and febrile symptoms increased; no pain; face pale and anxious. Dec. 29th.—Evidently weaker ; breathing labored; pulse 140, weak and thready; countenance of a yellow waxy tinge. There was profuse sweating this morning; other symptoms unchanged. Dec. 30th.—She continued to sink, and died this morning at 3 a.m., death having been preceded by repeated vomiting of dirty brownish-green matter. Sectio Cadaveris.—Thirty-three hours after death. Head not examined. Thorax.—Two drachms of clear serum in the pericardium; heart healthy; the right lung healthy, but its lower lobe and the diaphragm on that side were considerably pushed upwards by an abscess containing nearly a pint of pus, situated above the liver and below the diaphragm; the left lung also healthy, with the exception of a gangrenous ulcer, the size of a shilling, in the centre of the lower lobe inferiorly, where it rested on the diaphragm. This ulcer presented a brownish, broken up, sloughing surface, and was surrounded by red hepatization, occupying the pulmonary substance to about the extent of a hen's egg. Abdomen.—On reflecting the integuments, a considerable quantity of pus escaped from the abscess above alluded to on the right side, immediately below the diaphragm and above the liver. This abscess contained nearly a pint of pus, and was situated in a circumscribed pouch formed by the diaphragm above, the liver below, the peri- toneum anteriorly and externally, and false lymph of considerable tenacity internally. Lymph also glued these parts a.id the small curvature of the stomach together. On reflecting the integuments, the anterior wall of the abscess was removed, and so the pus escaped. The stomach, transverse colon, and coils of intestine in the superior third of the abdomen, were all glued together by bands and flakes of lymph, which, though of tolerable tenacity, were gelatinous in consistence, and could readily be torn through by the fingers. In the left hypochondrium there was a layer of this lymph half an inch in thickness, softened, purulent, and gangrenous in the centre, situated above the spleen, and communicating, by a sloughened opening, with the ulcer and hepatization in the lung formerly described. On cutting open the stomach, in the line of its large curvature, there flowed out a dirty, greenish-brown, grumous liquid, con- taining coagulated masses, apparently of milk, tinged of a dark-red color by port wine. In the posterior part of the stomach, about its centre, was observed an oval ulcer, the size of a five-shilling piece, with smooth, thickened edges, and surrounded by puckered folds of the mucous membrane, which was otherwise healthy. The ulcer was adherent to the pancreas behind, which constituted its base; but the adhesions round its supe- rior half were composed of the same gelatinous lymph as has been previously alluded to. On dissecting the ulcer from its attachments, it was seen to have completely per- forated the coats of the stomach, although the opening behind, viewed on the serous surface, was not above the size of a shilling. On removing the intestines from the pelvis, flakes of purulent lymph were observed between several of their coils and on the serous membrane of the pelvic cavity. All the other organs healthy. 486 DISEASES OF THE DIGESTIVE SYSTEM. Commentary.—All the facts connected with this case were obtained with great accuracy, and left us in little doubt, from the commencement that we had to treat a chronic ulcer of the stomach, which, on the morn- ing of the day she was admitted, had perforated the organ, and induced the violent pain she complained of. The peritonitis, which may have been induced by the perforation alone, was undoubtedly augmented by the brandy and water administered to rally her from the state of collapse into which she was thrown by the immediate effects of the accident. On entering the house also about five hours after she became ill, a stimulat- ing and anodyne draught was administered by the clerk to rouse her from her depressed condition. As this was followed by no increase of local pain, but by improvement of the vital powers, we may fairly conclude that the practice, though highly questionable, was not productive of injury. Nothing, indeed, is more natural on the sudden occurrence of violent pain in the epigastric region with a feeling of syncope, than to have re- course to stimulants, for perforations of the stomach are rare occurrences, and it is not every one who at such a moment, even among the profes- sion, has sufficient coolness and discrimination to detect the real nature of the disease. Hence, why so frequently these perforations are fatal, not so much from their own natural results as from the stimulating reme- dies administered, which pass through the aperture into the abdominal cavity. Indeed, had not brandy and water been given in this instance, there is every reason to suppose that the perforation might not have occasioned much mischief, for it occurred early in the morning, before breakfast, and long after her evening meal, and consequently when the organ was empty ; and, besides, it is to be observed that such perfora- tions have a great tendency to become re-closed by the rapid formation of fibrous lymph round their edges. In this case, however, extensive peritonitis was already occasioned when I first saw her, and the subse- quent treatment was directed—1st, To prevent the introduction of further matters into the stomach; 2d, To rally her from collapse by stimulating and nutritive enemata ; and 3d, To conduct the inflammation to a favor- able termination by local fomentations and opiates largely administered in the form of enemata, and subsequently in pills by the mouth. This treatment was attended with apparent success, so that on the fifth day nourishment was cautiously administered by the mouth, and also with tolerable benefit. On the eighth day, however, rigors appeared, followed by fever, which was attributed to a pleurisy on the right side, where in- creased thoracic dulness was discovered inferiorly, with loud friction and aegophony. Circumscribed pneumonia evidently also existed on the left side, as indicated bf crepitation. This formidable complication was attempted to be relieved by gentle salines, and topical bleeding by letches. It was soon apparent, however, from the appearance of dyspnoea and other symptoms, that there was now little hope of recovery, and notwithstand- ing the liberal use of stimulants, the patient sunk on the twenty-third day. Dissection exhibited exactly what was anticipated with regard to the stomach and peritoneum, but showed that the signs of the presumed pleurisy were occasioned by an abscess, which, by pushing up the dia- phragm and occupying the lower portion of the thoracic space on the right side, had given rise to all the physical signs of pleuritis. On the left side there was limited pneumonia as was expected, the lung com- ORGANIC DISEASES OF THE STOMACH. 487 municating by a gangrenous ulcer in the diaphragm, with the lymph ex- uded above and around the spleen. The edges of the ulcer of the stomach were firmly united to the pancreas, so that the patient undoubt- edly died from the extensive peritonitis. Case LXIII.*— Chronic Ulceration in the Stomach—Perforation occasioned by a Fall (?)—Recovery. History.—Barbara Ferguson, servant, aged 51—admitted January 6,1853. States that she enjoyed excellent health till about eight years ago, when she first began to complain of her stomach-suffering from pain of a cutting or grinding character, always worse after taking food. Her appetite has all along continued good, but she often experienced considerable thirst; has never had nausea or vomitmg. fene believes that she has been getting worse lately, but has had no distmct exacerbation On January the 4th instant, stepping upon a chair, her foot slipped, and she fell with the stomach across the back of it. She was immediately seized with intense pain m the epigastrium, rapidly extending over the whole abdomen. She did not faint, and was still able to speak, but had to be carried to bed. The accident occurred about 9 p. m., three hours after she had taken any food, which had consisted of some coffee, with a few mouthfuls only of bread. She was immediately ordered a one-gram pill of opium which was to be repeated every four hours. On the next day, as the acute pain still continued, four leeches were applied to the epigastrium, followed by warm fomentations. She has had nothing by the mouth except the opium pills, up to the date of admission. Symptoms on Admission.—On admission she appears very weak and nervous, and in a state of partial collapse; the countenance is sallow; pulse 100, weak; heart sounds normal; no headache, but a feeling of vertigo on attempting to rise or change her position; tongue clean, moist; no nausea or vomiting; appetite gone; considerable thirst; pain in epigastrium, which, with the whole abdomen, is excessively tender on pressure; she has had great dysuria and pain on micturition ever since the accident. All other functions are normal; ordered to have no food by the mouth, but an enema of beef-tea with the yolk of an egg immediately, to be followed in two hours by an opiate enema, with 40 minims of tincture of opium ; to be kept quiet and not get out of bed. Progress of the Case.—January 1th.—Was almost free from pain yesterday evening, and felt altogether much better, having slept a good deal during the afternoon. The beef-tea enema, with yolk of egg, has been repeated at intervals of four hours, and she had another opiate at 4 a. m., after which she slept well. To-day she feels easier; pain, or rather tenderness, in epigastrium somewhat diminished; and considerable pressure may now be exerted without causing uneasiness. She has still thirst; tongue dry; very little inclination for food; pulse 100, soft. Jan. 8th.—Was considerably easier last night, and expressed a desire for some food; the pulse was of better strength, 90. To-day is still improving; complains of no pain when lying quiet, but still pain on pressure in epigastrium; she expresses fear and pain when other parts are touched, but not to the same extent; pulse 95, of moderate strength. She has had the beef-tea, etc., enemata as before, with an opiate enema every 10 or 12 hours—to have beef- tea and milk by the mouth, in table-spoonfuls at a time, repeated every five minutes if the patient desires it. Jan. 9th.—Felt rather uneasy after taking the beef-tea and milk, which occasioned a sense of " working " in the stomach. An opiate enema was ordered in about two hours, and in the evening she expressed herself as free from un- easiness, and rather refreshed from the beef-tea. To-day she feels not quite so well, and her general appearance is more depressed. She has continued the beef-tea, but has had an egg and beef-tea twice a day in addition; pulse 88, of good strength; bowels have not been open since admission; to have a warm water enema, with an ounce of castor oil, followed, if necessary, by an opiate one. Jan. 10th.—Felt rather weak and exhausted after bowels were opened ; the opiate enema was administered two hours afterwards, and she has felt better since; had some tea, with a little toast, by the mouth this morning; takes beef-tea for dinner, but cannot eat rice or any farinaceous food; no bad effects have followed taking food by the mouth; pulse 88, of good strength ; little pain complained of, and she can now sustain considerable pressure on epigastrium without suffering. Slept less last night than before; urine clear, sp. gr. 1020, contains phosphates. Omit the enemata. Jan. 24th.—Since the last report she has been doing well, and gradually gaining strength. Dismissed. * Reported by Mr. F. S. B. F. de Chaumont, Clinical Clerk. 488 DISEASES OF THE DIGESTIVE SYSTEM. Commentary.—Many cases are on record of evident perforations of the stomach, which have been cured by judicious treatment, and the one just narrated seems to me to be an instructive example of this favorable termination of the lesion. The symptoms at the commencement were very like those of Case LXIL, but were induced by a blow on the epi- gastrium, instead of coming on after straining at stool. Violent pain, tenderness on pressure, and collapse were the immediate effects. For- tunately, I saw the patient immediately after the accident, and took care not to administer brandy or stimulating draughts. A grain of opium in the form of pill was administered every four hours, quietude enjoined, and complete abstinence insisted on. Next day the local pain continued, and on the following morning I sent her to the Infirmary. Nourishment was administered by enemata, and on the fourth day was cautiously given by the mouth, and no untoward, symptom ensued. From this time she slowly recovered. Of course we have no positive evidence that there was a perforation in this case. For eight years, however, she had been subject to severe attacks of pain in the stomach, increased on taking food, but there had been no vomiting. It is possible that the blow may have been sufficiently strong in itself to induce the pain and subsequent symp- toms, although, from all the inquiries I could make, it did not appear to be so. One of her fellow-servants indeed maintained that it must have been trifling. Wherever anatomical evidence fails, there must be more or less uncertainty hanging over the history of those cases which recover; but, taking all the circumstances into consideration, I cannot help think- ing that had brandy and water been given in this as in the former in- stance, there is every chance that here also fatal peritonitis would have been occasioned. From what I have observed of post-mortem examinations in the Royal Infirmary of Edinburgh, it does not appear to me that chronic ulcer of the stomach is a common disease here. Without having made any exact calculation, nothing positive can be said, but I do not think that the disease exists in more than 3 per cent of those examined; whereas in the Copenhagen and some German hospitals, it is said to vary from 6 to 13 per cent.* This frequency of it has been thought to be dependent on habits of intemperance and particular diet; and, if so, we might have anticipated that the habit of drinking raw whisky would have rendered it more common in Scotland than it appears to be. Its morbid anatomy was first admirably described and figured by Cruvel- hier.t The ulcer is chronic, of circular or oval form, generally varying in size from a fourpenny to that of a crown-piece, having an abrupt, slightly thickened margin, as if it had been punched out, and an indurated smooth base. It may be shallow or deep, and frequently perforates all the coats of the stomach, in which case the external is larger than the internal aperture. It has a great tendency to contract adhesions by its external borders to neighboring viscera, more especially the pancreas, immediately over which, in the posterior wall of the stomach, the ulcer is most commonly situated. When it occurs in the anterior wall, it less * See an able Memoir on the subject by Dr. Brinton. London, 1857. f Anat. Pathologique. Liv's. x. et xx. ORGANIC DISEASES OF THE STOMACH. 489 readily contracts adhesions, and therefore is more likely to induce per- foration. The ulcer may heal at any period of its progress, leaving a cicatrix, which varies in appearance according to the amount of tissue previously lost. Sometimes there is a mere scar, at others a stellate puckering. Occasionally there is a dense thickening with rigid folds, causing contractions in one place, and pouches in another, and this con- traction may even be circular, causing a stricture of the_ organ. Mineral deposits are now and then found adherent to the cicatrix. The three leading symptoms of chronic ulcer of the stomach are pain, increased on pressure, vomiting after taking food, and haematemesis. Of these, the last is the most important in a diagnostic point of view, be- cause its presence renders certain, what would otherwise only be conjec- tural. The disease, however, may exist without as yet having so injured a blood-vessel as to occasion hemorrhage. Hence the symptoms of chronic dyspepsia, with vomiting after food and fixed pain, if long con- tinued, should invariably give rise to the suspicion of an ulcer, and lead to an appropriate treatment. The remedies I have found most efficacious, in simple chronic ulcer of the stomach, are quietude, careful regulation of the diet, bismuth and opium pills or powders, and sometimes warmth, at others cold applied locally. It may frequently be observed that the mere coming into a hospital and remaining quietly in bed has a favorable effect in modi- fying the distressing symptoms. I have also remarked that those patients who are always getting up and walking about suffer much more than those who remain in bed, especially at the commencement of the disease. Hence, repose in an easy position should be enjoined. The diet should consist of farinaceous pulpy substances, occasionally mixed with beef-tea, or milk, given in small quantities frequently repeated. If the stomach will not tolerate the food warm, it should be given cold. When, despite this treatment, vomiting continues, it is best to suspend all nourishment for a day or two, and give nutritive enemata. As the patient gets bet- ter, the amount of solid food should be very cautiously increased. Thirst is a distressing symptom in such cases, and is best allayed by allowing ice to dissolve in the mouth slowly, or sipping, at intervals, milk and limewater, mingled in equal proportions. The pain is alleviated best by bismuth and opium, combined in the form of pill or powder. Some- times local warmth, but more frequently pounded ice, mixed with salt in a bladder, applied over the part, will give relief. Two or three leeches, or a counter-irritant, may succeed when everything else fails, and should be tried. Quietude and suspending all ingesta for a time, I believe to be the best remedies for hemorrhage, and where exhaustion from want of food exists, nutrient enemata, with wine, must be administered. When a perforation occurs, I have already pointed out the great im- portance of avoiding the giving of stimuli by the mouth (Cases LXII. LXIIL), and have stated the practice which should be perseveringly followed, namely, the administering of opium in the form of pill, quiet- ude, avoidance of purgatives, and nourishing at first by enemata, and then cautiously by unirritating substances, given in small quantities by the mouth. 490 DISEASES OF THE DIGESTIVE SYSTEM. LXIVft—Cancer of Stomach, Pancreas, and Mesenteric Glands—Cystic Atrophy of Right Kidney. History.—Thomas Gaffney, set. 50, married, a laborer—admitted November 24 1856. States that up to twelve months ago he was in good health, but since that time he has been troubled with pyrosis, occasional vomiting, and diminished appetite. Three months ago, feeling much pain in the epigastrium, he noticed that he had a tumor in that region. It was very sore, continued to increase in size, and became more and more painful. At present he is very emaciated, and suffers severe pain in whatever position he places himself. Symptoms on Admission.—Teeth and gums dry ; tongue dry, with a longitudinal fissure down the centre. Thirst only occasionally felt. Has no appetite. Has no difficulty in swallowing; but complains of constant pain in the epigastrium. It is not distinctly increased on taking food. The food cannot be retained on his stomach, coming up in mouthfuls from an hour to an hour and a half after ingestion. The vomited matter is described as resembling in color coffee grounds. On examining the epigastrium in the mesial line, two inches below the ensiform cartilage, and three inches above the umbilicus, there is felt a small tumor about the size of a walnut, of an irregu- lar margin superiorly. The convex surface looks outwards and downwards. It may be moved upwards and to the right, but not downwards or to the left. In left half of epigastrium, over a space of two square inches, there is dulness on percussion, and on palpitation, a deep-seated, strongly-resisting tumor is felt, with a distinct margin to the right side. It appears to pass upwards under the superior part of left hypochondrium, where percussion gives forth a comparatively dull resonance. Percussion elsewhere over abdomen, tympanitic. Over the hepatic organ and over the tumor there is great tenderness on percussion. Occasionally the tumor is felt more distinctly, and is then rough and nodulated. The chest is barrel-shaped. Percussion is unusually resonant. Respiration is feeble anteriorly and is harsh posteriorly, the expiratory murmur being prolonged. No dyspnoea. Sputum scanty. Precordial region unusually resonant on percussion. Transverse dulness, two and a quarter inches. Cardiac sounds healthy, but feeble. Apex of heart cannot be felt. Pulse small and weak, 68 per minute. Sleeps but little. Urine normal. The diet is to be carefully regulated ; small quantities of nutri- tive food and wine to be taken at frequent intervals. A mixture of snow and salt put into a bladder is to be applied over the tumor. To take two of the following pills every night: R Morph. Acet., gr. iss ; Conserv. Rosar., gr. xij. Fiat massa in pilulas sex dividenda. Progress of the Case.—December 1st.—The local application of cold has aiforded him considerable relief, so much so that he does not like to be without it. He is unable to take a sufficient amount of aliment, and is gradually getting weaker. Dec. 4th.—The pills at night continue to lull his pain. His diet consists of strong beef- tea three half pints per diem; bread and milk; milk and rice pudding; with six ounces of wine. Patient always vomits after eating, however little, and continues to sink. Dec. 5th.—Died at 10.30 a.m. Sectio Cadaveris.—Twenty-eight hours after death. Abdomen.—Permission could only be obtained to examine the abdomen. On opening the stomach it was seen to contain a considerable quantity of yellow pultace- ous substance, being half-digested food tinged with bile. The pyloric orifice was compressed by a mass of cancerous exudation, seated in the smaller curvature, and projecting into the stomach; this mass was about 5 inches in diameter, rounded at the margins; nodulated internally with two projecting portions, so situated as to act as valves in front of the pyloric orifice, through which a finger could be easily passed behind them. The thickness of this mass was in one place two inches, gradu- ally diminishing towards the margins to half an inch. The tissue was friable, easily breaking down under the finger, but not yielding cancerous juice. The pancreas was generally healthy, but an inch of the duodenal extremity was involved in the cancerous tumor. The cardiac orifice, which was half an inch from the margin of the cancerous tumor formerly described, was quite healthy, as was the rest of the stomach not involved. Several mesenteric glands in the neighborhood of the pan- creas were enlarged, nodulated, and filled with cancerous exudation. Anteriorly the stomach was strongly adherent to a portion of the liver, which below, over the tumor described, felt hard and nodulated. In the position of the right kidney was a cyst, the * Reported by Mr. William Guy, Clinical Clerk. ORGANIC DISEASES OF THE STOMACH. 491 Bize of the human head, containing a yellow serum. Internally it presented a smooth serous surface, here and there interrupted by circles, and fragments of circles leading into pouches. Some of these openings were perfectly circular, with smooth abrupt mar- gins, and were about the size of a fourpenny piece ; others were about the size of half a crown or five shilling piece. Here and there, on the surface of the serous membrane, were corrugated indurated lines with black calcareous plates upon them, the result of cicatrizations. Externally the pouch was smooth, covered with shreds of cellular tissue; at its inferior portion was an induration, measuring two inches in length, and being cut into four, was found to consist of cortical renal substance about one-sixth of an inch in thickness. Immediately behind this renal substance was a cyst, communicating with one of the pouches previously described, about the size of half a crown. No trace of tubercular structure could anywhere be seen. A portion of lung was also removed about two inches square; it was spongy throughout, but presented gelatinous-looking masses, about one-sixth of an inch in diameter, scattered through its substance. They could be squeezed and compressed between the fingers, but had a certain amount of firmness. On section they pre- sented a smooth surface of grey color. Microscopic Examination.—The cancerous mass in the stomach presented cancer cells in all stages of formation, with granule cells here and there embedded in masses of molecular substance. The mesenteric and epigastric glands on being cut presented a fragile surface, from which a glutinous substance could readily be scraped. This contained, when examined microscopically, large cancer cells multiplying endogen- ously; here and there granule cells, with a few fibres and numerous molecules. The rounded masses in the lung were of the same structure. Case LXV.*—Colloid Cancer with perforatiny Ulcer of Stomach— Peritonitis. History.—James Douglas, aet. 55, a porter—admitted September 15,1854. About fourteen weeks ago, being previously quite healthy, he began to experience a burning pain in the epigastrium, more severe after taking food, and also a sensation as of a ball rising in his throat. For three weeks he continued to work, but gradually grew worse; eight weeks ago, he vomited, for two days, dark colored matter like coffee grounds. Has since been troubled with pyrosis, has lost his appetite, and become weaker and thinner. Symptoms on Admission.—Is greatly emaciated. Tongue moist, slightly furred; appetite bad; no dysphagia; feels pain in the epigastric region constantly of a burn- ing character, more severe after taking food; no vomiting, but has eructations of a thin watery fluid. The epigastrium feels hard on palpation; in the region of the umbilicus there is a distinct tumor stretching across the abdomen ; movable under the integument; not very tender to the touch. Bowels habitually costive. Has no cough, Pulse 56, weak. Urine not coagulable, of sp. gr. 1019. Other systems normal. Progress of the Case.—September 15th to October 9th.—The patient has been treated by the administration of antacids, bismuth, and magnesia; by the injection of nutritive enemata; by occasional opiates at night; by suitable aperients, and care- ful regulation of the diet. He has gained no strength; is indeed much weaker; at present he has a burning sensation along the whole course of the oesophagus. Oct. 13th.—This morning experienced acute pain in the abdomen, which is now distended, and generally painful on pressure and deep inspiration. Pulse 84, pretty firm. Eight leeches were applied to the abdomen, followed by warm fomentations, and opium in grain doses. Oct. 14th.—Has had much vomiting this morning, of dark coffee- colored fluid; pulse is feeble, and extremities are cold. While eating his dinner to- day, he fell forward, and immediately expired. Seetio Cadaver is.—Twenty-two hours after death. Body very much emaciated. Thorax.—Thoracic organs normal. Abdomen.—On opening the abdomen a large quantity of dark-colored fluid was found, in which were suspended flakes of white lymph. To the inner surface of the peritoneum pieces of soft recent lymph were attached, but it was quite free of small round nodules. The stomach and the intestines were loosely glued to each other and to the parietal peritoneum by soft lymnh. The fingers alone were sufficient to * Reported by Mr. Robert Rhind, Clinical Clerk. """ 492 DISEASES OF THE DIGESTIVE SYSTEM. separate the bowels. On examining attentively the anterior surface of the stomach two or three small perforations could be detected. The largest was nearly an inch long on the outer surface of the stomach, and corresponded to an ulceration about 2-£ inches in extent internally. The pyloric half of the stomach was transformed into a large, intensely hard, glue-like mass, and was about the size of a cocoa nut, or two closed fists. On opening the stomach, the mucous membrane, towards the car- diac extremity, was perfectly sound, but at the pyloric end it had undergone ulcera- tion at several points, especially near the smaller curvature and the pylorus. The pyloric orifice was of sufficient diameter to admit easily the little finger. The pancreas, liver, and surrounding organs were healthy. The texture of the growth was as hard as cartilage, and creaked under the knife, but on section presented the usual charac- ters of colloid cancer. (See p. 232.) The mucous membrane of the intestines was perfectly healthy. The other abdominal organs were normal. Microscopic Examination.—The colloid cancer presented the characteristic struc- ture described and figured p. 232. Commentary.—An indurated swelling in the epigastric region, pain and vomiting after food, are the usual symptoms of cancer in the stomach; and they were all present in the two cases just noticed. There was, besides, haematemesis, indicating ulceration in Case LX., and in addition, sudden pain, with peritonitis, in Case LXL, pointing out the occurrence of perforation. The vomiting did not appear so soon in the last as in the first case, and it will be noticed that in it the pyloric constriction was not great. On the other hand, ulceration was more extensive with pyrosis, and led to perforation with fatal peritonitis. The atrophy of the right kidney, which was converted into a fibrous sac, had not apparently in Gaffney produced any complaint whatever during life. All the symptoms observed in this man, with the excep- tion of hasmatemesis, may be produced by a tumor outside the stomach, as well as by disease of the stomach itself, pressing on the organ, and nothing is more difficult (if indeed it be ever possible) than to diagnose the former condition from the latter, which, however, occurs rarely. (See p. 520.) In many cases the lesion hitherto described as scirrhus of the pylorus or stomach seems to be a simple hypertrophy of their muscular and fibrous coats, which may or may not be associated with cancer of the neighboring glands. A simple stricture of the pylorus may in this way produce more or less thickening of the stomach, in consequence of the chronic vomiting excited by it; or by increasing the muscular power necessary to overcome the obstruction, just as happens in the intestines, bladder, and other hollow viscera, when the parts below them are strictured. (See Figs. 170 to 172, p. 190.) I have recorded four cases of this kind in my work on " Cancerous and Cancroid Growths" (Edinburgh, 1848, p. 46, et seq.) In all such cases it is observable, that the same emaciation and cachectic appearances are present as in instances of undoubted cancer—a circumstance which is attributable to the impeded nutrition of the body rather than to a supposed cancerous diathesis. On this account I have long ceased to place any confidence in the so-called "cachectic appearance" as diagnostic of cancer, attribut- ing it either to imperfect nutrition, or to wearing down of the body from excessive pain. This cachexia is often present in many other forms of morbid growth, and frequently absent when the disease has been proved to be cancerous by a microscopic examination. Of all forms of cancerous disease, that of the stomach is perhaps the DISEASES OF THE STOMACH. 493 most distressing; it cuts off the supply of nourishment which should enter the system, and induces (in addition to the wearing-down pain,) loss of sleep, loss of blood, and more or less constant vomiting. Our duty in such cases is to relieve and support the system; and to this end opiates in large doses, nutritive enemata, careful regulation of the diet, and ice allowed to dissolve in the mouth, are the best remedies. A local frigorific mixture, as recommended by Dr. J. Arnott, and the ap- plication of a few leeches to the epigastrium, are also occasionally bene- ficial. In Case LX. the cold application was of marked service. The histological changes which occur in various disorders of the stomach were first investigated by Dr. Handheld Jones, who has described and figured the appearances presented by the follicles, their contained cells, and other minute structures' under a variety of circum- stances* There may be hypertrophy and atrophy of the solitary glands; atrophy of the glandular tubes; fatty degeneration; wasting and black discoloration of their epithelial contents; fibroid thickening, Fig. 417. Fig. 418 Fig. 419. etc. His researches have been for the most part confirmed by Dr. F. Schlapferf and Dr. Wilson Fox. J The latter observer has added some important facts connected with chronic catarrh of the stomach, thicken- ing of the limitary membrane, and cystic degeneration of the glands. * Pathological and Clinical Observations respecting Morbid Conditions of the Stomach. London, 1845. f Virchow's Archiv. B. 1, p. 158. 1854 % Medico-Chir. Trans, of London. Vol. XLI. 1858. Fig. 417. Appearance of the gastric glands in recent catarrh of the stomach. Their external outline is irregular, and they are filled with enlarged secreting cells. —(Wilson Fox.) Fig. 418. Commencing cystic formation in a gastric follicle, which is constricted in some places (b, c) and swollen at others, a, Shows the thickening of the limitary membrane; and d, slight fatty degeneration of the epithelium —(Wilson Fox.) Fig. 419. A cyst in the pyloric portion of the stomach, composed of a fibrous envelope, and contents wholly composed of cylindrical epithelium. At a, the limi- tary membrane of the gastric glands commences to be thickened; and at b, their contents have undergone the fatty degeneration, so common in chronic catarrh.— (Wilson Fox.) 340diam. 494 DISEASES OF THE DIGESTIVE SYSTEM. Dr. Habershon,* as well as Dr. Fox, points out the rapid changes which take place in the glands of the stomach after death, and the great caution therefore required in forming conclusions, when examination of the minute structure is too long delayed. As a guide to the clinical student and practitioner. I give the more important morbid changes which have been observed in the gastric glands, from the excellent representations of Dr. Fox. Dr. Jones has the great merit of having laid the foundation for a clinical history of these lesions, although the observations are as yet far too few to enable us to connect them with diagnosis and treatment at the bed-side. From what is known on this subject, I must refer to the works I have named, hoping that before Fig. 420. Fig. 421. Fig. 422. long these researches may be extended by clinical histologists, and ulti- mately lead to a more exact knowledge of the dyspeptic and organic diseases of this important organ. As a further contribution to this subject, I may observe that in the case of a man—Robert Lindsay—aet. 60, who died in the clinical ward, March 27, 1860, with a well-marked tumor of the pylorus, a careful histological examination revealed the following facts. The history of the case, and the appearance presented by the thickened structure of the pylorus, presented nothing unusual. Various sections through the thickened and indurated white pyloric structure, with a Valentin's knife, showed the morbid growth to be composed of hypertrophy of the gastric follicles, as represented Fig. 423. The cells of some follicles had undergone the fatty degeneration, so that they were filled with molecular and granular matter, in which * On Diseases of the Alimentary Canal, p. 52. 8vo, bound. 185*7. Fig. 420. The gastric glands in chronic catarrh of the stomach, the breaking down of the upper portion being probably due to post-mortem change, a, a mass of pigment; b, b, free fat drops; c, thickened limitary membrane; d, d, d, complete fatty degeneration of the epithelium.—(Wilson Fox.) Fig. 421. Chronic catarrh of the stomach, with hypertrophy of the fibrous tissue between the glands. The section has been treated with acetic acid, which exhibits more distinctly the nuclei of the fibrous tissue, and gives a cloudy appearance to the follicular epithelium.—(Wilson Fox.) Fig. 422. Fatty degeneration affecting the upper layer of the follicular epithelium, c, and fibrous connective tissue, a, a, producing erosion of the surface; b, fatty degeneration of the epithelium and sub-mucous fibrous tissue.—(Wilson Fox.) 340 diam. DISEASES OF THE STOMACH. 495 all structure was lost. In others, however, even where the follicles Fig. 423 were enormously distended, as seen at d in the figure, the gland struc- ture was still preserved. Case LXVL*—Poisoniny by Oxalic Acid—Recovery, History.—Thomas Clarke, set. 47, shoemaker—admitted May 21st, 1859. He was brought to the hospital by the police at 9.10 p.m. At 8 p.m. he had swallowed a penny- worth of oxalic acid (about 6 drachms), partly dissolved in a tea-cupful of water, and partly in a crystalline state. At about 8.20 p.m. he was conveyed to the police-office, where he vomited twice, and refused to take some medicine which was offered him. He was then brought to the Infirmary. Patient stated afterwards that about 8.20 p.m. he felt a burning sensation in the lower part of the oesophagus and stomach, which * Reported by Dr. Carter, Resident Physician. Fig. 423. The gastric and pyloric glands hypertrophied in a cancroid tumor of the pylorus, a, Enlarged follicle; b, transverse section of such a follicle; c, out- line of another follicle; d, the largest follicle observed, mostly drawn in outline. The whole of it, however, was composed of enlarged epithelial cells, as seen in the upper part of the drawing. In the centre the appearance of the isolated cells is seen, which were very numerous in the field of the microscope, e, Fragment of a follicle; many of these of all sizes and shapes, resulting from sections in various directions, were observed, as will be at once understood by the histologist. /, Mass cf cells undergoing the fatty degeneration, g, Another mass completely disinte- grated. The follicles presented all sizes and shapes intermediate between a and d, and many of them all the stages of fatty degeneration. 250 diam. 496 DISEASES OF THE DIGESTIVE SYSTEM. was followed by vomiting. The matters thrown up consisted of some bread which he had taken at about 5 o'clock p. m., and some of the crystals of the acid. Symptoms on Admission.—At the time of admission—9.10 p.m.—he was pallid- skin cold, but without moisture; his features pinched; pupils if anything rather dilated; pulse 12 and weak. He complained of burning sensation about his gums the lower part of his throat, and in his stomach, which latter was very painful when pressed upon. He answered questions intelligently, but was unwilling to give much information. He vomited twice after entering the hospital, and was seized with a rigor which lasted for about ten minutes. An attempt was made to pass the stomach pump tube, but as this seemed to occasion excessive pain, and as he had vomited so frequently, it was not employed. He was, at 9.25 p. m., made to drink about three parts of a pint of warm water, in which was suspended one ounce of prepared chalk. This remained on his stomach for about ten minutes, and was then rejected. He said that he felt immediate relief from the burning sensation after he had taken the chalk. A similar dose was again administered and retained permanently. He was placed in a bed a short distance from the fire, and warm bottles applied to his feet. At 10.30 he felt much better, and took about half a pint of strong beef-tea, with an ounce of brandy in it, and was ordered to have the same mixture at 1 o'clock, and to drink milk ad libitum throughout the night if thirsty. Progress of the Case.—May 22d.—Expresses himself as feeling tolerably well; but complains of some slight uneasiness in his throat and stomach, and of weakness, which, however, he has felt for some time as a consequence of illness and of privation. His tongue is covered with a thickish fur; he has little appetite and great thirst; his bowels were open during the night. Pulse 60, still weak. He continued to feel pain in the stomach, with dyspeptic symptoms, for some time; similar, he says, to those he labored under before taking the poison. These were diminished and ulti- mately got rid of by powders containing five grains of bismuth, and a quarter of a grain of opium. He was dismissed cured, June 13. Case LXVIL*—Poisoning by Sulphuric Acid—Recovery. History.—John Calder, set. 2—admitted July 21st, 1863. This healthy child shortly after breakfast, having been left alone in a room, was heard by its mother to utter a scream. He was found with a bottle in his hand containing sulphuric acid, which he had applied to his mouth, and from which he had subtracted about § ij. Some of this had been spilt on the child's chin, breast, and clothes. Water was given to it, and the child immediately brought to the Infirmary in its mother's arms. She says that on the way a brownish colored fluid, with the milk and bread previously eaten, was vomited. Symptoms on Admission.—The resident physician on hearing the nature of the case, immediately administered 3 ij of carbonate of magnesia suspended in water, when the child eructated a considerable quantity of gas. The pulse then was 100, weak; sur- face pale; tongue of a dead white, as if acted on by the acid, which has also flowed over»the lower lip, chin, and breast. Otherwise the child was quite healthy. Progress of the Case.— Vespere.—Up to this time the child has been quiet, dozing occasionally. Deglutition is painful, but milk and beef-tea have been given at inter- vals. Has had one stool; pale and pultaceous. July 22d.—Has passed a restless night, but this morning does not seem to suffer much pain. Chalk in lime water has been given from time to time during the night, and a beef-tea enema this morning, which was retained. Pulse 145, weak. The tongue, a few patches inside the mouth, the centre of the lower lip and chin, forming a streak about an inch broad, are covered with eschars. There is another also, the size of half a crown, on the breast. July 23d.—Takes nourishment with some pain on swallowing. Desquamation of the dorsum of the tongue has taken place in patches. July 24th.—Eschars have separated. July 25th.—Still slight pain on swallowing, otherwise well. Dismissed. Cask LXVIII.f—Poisoning by Corrosive Sublimate—Recovery. History.—Alexander Tweedle, set. 19—admitted May 24th, 1861. He stated that a quarter of an hour previously he had swallowed by mistake, instead of whisky, * Reported by Mr. Alfred Lewis, Clinical Clerk. \ Reported by Mr. John Simpson, Clinical Clerk. DISEASES OF THE LIVER. 497 half a wine glassful of a bottle marked poison, which was found to contain camphor, turpentine, and corrosive sublimate, and used to destroy insects. Had not vomited since. . ,. Symptoms on Admission.—Only complained of great dryness and heat in ms throat, otherwise was quite well. An emetic of sulphate of zinc (gr. xx) was imme- diately given, and a quantity of fluid, smelling strongly of camphor and turpentine, was at once ejected. The whites of six eggs were then administered. The tests of caustic potash, iodide of potassium, copper and nitrate of silver, indicated a consider- able quantity of corrosive sublimate in the fluid contained in the bottle he had brought with him. Progress of the case.—May 25th.—Complained of no bad symptoms last night; slept well—dismissed. Commentary.—In the first of these three cases of irritant poisoning, the man was induced to commit suicide when laboring under dyspepsia, want of food, and impossibility of obtaining employment. In the second case—that of a young child—vomiting having occurred before admission, an antacid was immediately given, which neutralised what was left of the sulphuric acid in the stomach. Fortunately also the irritant was swallowed shortly after taking a meal. In the third, case, an _ emetic acted perfectly before the corrosive sublimate had time to occasion bad consequences, and white of eggs was at once administered. Prompt judicious measures induced in all of them recovery. DISEASES OF THE LIVER. Notwithstanding the obscurity which still rests upon the functions of the liver, the progress of histological pathology has tended to make us better acquainted with the minute changes which oocur in many diseases of the organ. The nature of fatty enlargement, of cirrhosis, and of the disintegration of cell-texture following obstruction of the bile-ducts, is now understood, but much research is still necessary. A careful comparison of the structural changes observed in the liver after death, with the clinical history and symptoms observed in the liver during life, is what is greatly desired to advance our knowledge of hepatic diseases. This knowledge, however, can scarcely be hoped for, until medical men, and especially such as practise in the East, become efficient histologists. More recently some light has been thrown upon diagnosis, by paying attention to the transformations which bile undergoes during its excre- tion by the kidneys. It is the application of therapeutics to these diseases, however, and a correct appreciation of the class of remedies called cholagogues, which in the present state of medicine, requires most to be determined. Such an investigation necessitates physiological, histological,, and chemical knowledge, added to good powers of clinical observation. But of all the subjects of research now open to the young investigator, I know of none in which patience and exactitude, based on a scientific rather than an empirical system of inquiry, is likely to yield more useful results. Case LXIX.*—Acute Congestion of the Liver—Hepatitis—Recovery. History.—Thomas Russell, set. 38, laborer at a gas-work—admitted January 26th, 1855. States that about three weeks ago, after indulging freely in the use of * Reported by Mr. W. J. Marshall, Clinical Clerk. 498 DISEASES OF THE DIGESTIVE SYSTEM. ardent spirits, he experienced general shivering and pain in the right hypochondrium with tinnitus aurium and a sense of faintness. Subsequently he felt pain in the right shoulder, and at length was obliged to leave off work. His comrades who went home with him, told him that he looked yellow in the face. At night he became very hot. He returned to his work on the following day, and continued at his employment for a fortnight, but was very weak, and suffered much from the pain in his side, and in the shoulder. Since then he has been confined to bed, under medical care, applying counter-irritants locally, and taking pills which have made his mouth sore. Symptoms on Admission.—On admission, he complains of pain in the right hypo- chondrium and right shoulder, in the former of which situations it is permanent and increased by pressure, while in the latter it is only occasional. The tongue is covered with a moist white fur ; the breath has a mercurial foetor; the gums are painful; appe- tite good. Bowels open. Pressure and percussion over the liver painful. Vertical hepatic dulness 4£ inches. Pulse 12, soft. Sleeps little in consequence of the pain; Urine normal; no jaundice. Other functions well performed. To apply six leeches to the right hypochondrium, and the parts afterwards to be fomented. To take two compound rhubarb pills every night. Progress of the Case.—February 1st.— The leeches and fomentations have in no way benefited the pain, which to-day is as severe as on admission. Bowels still open. Stools darker than formerly, but healthy. February 3d.—Since last report all pain has left him; he declares himself to be well, and at his own request was discharged. Case LXX.*—Acute Jaundice.—Albuminuria.—Recovery. History.—Walter Halliday, set. 51, tailor—admitted July 6th, 1857. States that he has generally been a temperate man, although occasionally he has taken spirits moderately. On the first of this month, when working below an open window, he was suddenly seized with rigors, followed by great thirst, heat of skin, and headache. Next morning he went to work as usual, but was obliged to desist in the middle of the day and go home. The rigors have returned occasionally ever since, and he has experienced obscure pain in the lumbar region. The skin became jaundiced on the second day of his illness, and the yellow tint has been increasing in intensity since. He has also occasionally vomited. Symptoms on Admission.—The tongue is moist and covered with a whitish fur. No difficulty in taking food, nor pain afterwards. No tenderness or pain in abdomen ; but feels a pain in the lumbar region, which sometimes darts round the right side towards the umbilicus. Appetite impaired. Bowels costive. Vertical dulness of liver on percussion 4 inches. The skin over the whole body is of a deep yellow tint, dotted with spots of purpura the size of pin heads ; but is cool and moist. The urine is deep colored, like Madeira wine. It is very albuminous on the addition of heat, and contains a large quantity of bile. Pulse 88, small and weak. Other organs healthy. R Potass. Acet. 3 ij.; Sp. ^Ether. Nit. fss; Aqua % vi; M. One ounce to be taken every three hours. July 8th.—Bowels were freely opened yesterday in conse- quence of a Calomel and Jalap powder which was given. Stools were fluid and of a dark-brown color. Progress of the Case.— Jidy 9th.—On microscopic examination of the urine it was seen to contain numerous casts, with delicate walls, having in their interior large epithelial cells. Passes more urine than formerly. To have Pulv. Doveri gr. x, at bed-time, followed by a diaphoretic draught. Two compound rhubarb pills to betaken every night. Jidy 12th.—The urine and skin are now of a healthy color. The pulse, however, remains low, and the patient weak and languid. Nutrients, tonics and wine, with gentle exercise, were now given, under which he became thoroughly well, and was discharged August 3d. Commentary.—These two cases are examples of the slighter forms of hepatic disease, although what that disease is it becomes no easy matter to determine. In the first case we have pain, increased on pressure in the right hypochondrium, and in the right shoulder, ushered in by rigor and febrile symptoms. On percussion the liver is found to be slightly enlarged. After coming into the house the disease subsides * Reported by Mr. W. H. Davies, Clinical Clerk. DISEASES OF THE LIVER. 499 in a few days. The leeches and fomentations did not seem to alleviate the pain, but the purgative produced a more healthy intestinal discharge. In the second case there was little local pain, but evidently something had caused interference with the secretion of bile. The skin was deeply jaundiced, the stools of a dark clay or leaden color, and the urine loaded. This condition was also ushered in with rigors and febrile symptoms. Ptyalism was produced before he entered the house, without occasioning the slightest benefit. On the contrary, the disease increased. But under the action of diuretics and diaphoretics, to favor secretion of the bile already absorbed, as well as of mercurial purgatives to rouse the duodenum and upper parts of the alimentary canal to a more healthy action, he rapidly recovered. Whether the disorder in these cases was congestive or inflammatory, or both, cannot be de- termined. Whatever the lesion, it so operated in the one case as to induce great pain, and in the other to obstruct the gall-ducts and occa- sion jaundice. In jaundice, the diminished excretion of bile by the intestines is attempted to be compensated for by its entering more or less largely into the secretions of the kidney and skin—especially the former. In intense forms of the disease, casts of the renal tubes are frequently seen in the urine, their contained cells deeply tinged with bile pigment. Frerichs has carefully described and figured the histological changes which occur in the kidneys and skin under such circumstances. These consist in the accumulation of yellow, brown, and green pigment, in the cells of the tubuli uriniferi, and, not unfrequently the pigment is infiltrated through the parenchymatous tissue of the kidney. He has even seen it assume the form of hard coal-like masses, which must have greatly interfered with the functions of the organ. In the skin the deep layer of round epidermic cells contain a yellowish or deeply brown granular pigment, and the secreting cells of the sudoriferous glands are similarly affected, but never to the extent which may be observed in the kidney.* Such observations indicate the importance of diuretics and sudorifics in the treatment of jaundice, in addition to the means usually adopted for stimulating the upper part of the alimen- tary canal. A new impulse has been given to the diagnosis of the causes on which jaundice depends by the writings of Frerichs, Harley, and others. Jaundice may be a symptom—1st, of various affections of the blood, as in fevers, disease of the heart, lungs, and nervous system; 2d, of mechanical obstruction in the duodenum, from accumulation of faeces in neighboring bowels, or from tumors; 3d, of hepatic congestion, occa- sioned by fright and other temporary circumstances; 4th, from obstruc- tion of the ducts in the liver itself or the gall-bladder; and 5th, from structural changes in the hepatic tissue. Hence jaundice may be con- veniently divided, as was originally done by Dr. Alison, into jaundice from obstruction and jaundice from non-elimination. The symptoms are chiefly referrible to the skin, which is tinted yellow; to the bowels, the discharges from which are clay-colored, and * Frerichs, Klinik der Leber Krankheiten, 1858, pp. 107-8, and plate 1. 500 DISEASES OF THE DIGESTIVE SYSTEM. more or less fatty; and to the urine, the chemical constituents of which vary greatly. It is by the chemical analysis of this fluid, that new light has been endeavored to be thrown on our appreciation of the nature of jaundice. In our attempts to arrive at results by the chemical investi- gation of this fluid, we must first remember what are the constituents of bile; and, secondly, how they are to be detected. The chemical constituents of bile are—1st, Biliverdine,—a green, nitrogenized, non-crystallizable coloring matter derived from the blood. 2d, Two acids,—the glycocholic, which, with soda, is crystallizable; and the Taurocholic, which is non-crystallizable. 3d, Cholesterine,—a fatty crystallizable matter. 4th, A brown resinous matter, resembling shoe- maker's wax. 5th, Sugar. 6th, Inorganic matters, chiefly soda, potash, and iron. When the secretion of bile has been suppressed, that is, when this fluid has not been formed, it is said that no bile acids are to be found in the urine; not having been formed, they do not enter the blood and are not excreted by the kidneys. It must be confessed, however, that we require more characteristic tests for the bed-side than those furnished by Pettinkofer (p. Ill), or by the method of Hoppe. To me it has not appeared, from numerous trials, that any amount of skill and experi- ence will ever enable the physician to come to a conclusion on this point, when all that has to be determined is the difference between a rich brown and a purple color—constantly passing as they do into one another—in order to distinguish the absence or presence of an acid, on which depends a conclusion so important. According to Frerichs, acute atrophy of the liver is to be determined by the presence of tyrosine and leucin in the urine—two products never found there in health. (For mode of detection see p. Ill, and Figs. 112 to 114.) I have endeavored to ascertain the correctness of this test in several cases which entered the clinical wards during the years 1863-64, but only succeeded in obtaining unequivocal crystals of leucin in one case. Here, also, I believe that unless the mode of detec- tion can be simplified, it will be some time before we shall be enabled to judge of the correctness of this new diagnostic sign. Notwithstand- ing the trouble I and my various assistants have recently taken in en- deavoring to arrive at useful results,* by these new modes of inquiry, the facts I have arrived at are as yet too few and uncertain to warrant publication. The true method of further investigating these matters, however, m to extend chemical and histological knowledge among medical students, so as to obtain a larger number of skilful workers at the bed-side, who have time and ability to grapple with the present difficulties of such questions. The profession at large cannot be too grateful to those who have indicated new sources of information in diseases hitherto so mysterious, which I firmly believe are yet destined to yield most im- portant results. * Among these I am much indebted to my late resident physicians, Drs. Smart and Duckworth. DISEASES OF THE LIVER. 501 ^ase LXXI.*—Abscess of the Liver, bursting into the Right Thoracic Cavity, and into the Retro-peritoneal Cellular Tissue—Pneu- monia and Gangrene of Right Lung—Pneumo-Thorax. History.—Robert Steinkopff, set. 45, native of Prussia, merchant—admitted Nov. 5, 1864. The patient states that he was in easy circumstances; passed his time chiefly in hunting, and in so doing he was often accustomed to the free use of spirits; until a year ago, when he lost his property and came to this country. He was now obliged to live on very insufficient diet, and this, combined with great mental anxiety, impaired his strength. Three weeks ago, after exposure to wet on a rainy day, he was seized with sudden and severe pain in the right hypochondriac and epigastric regions; en- largement and protrusion of the abdomen, more especially when standing; diarrhoea of six thin and copious stools per diem, accompanied with much flatus; feverish attacks, occurring every afternoon from 3 to 6 o'clock; diminished appetite and con- stant thirst. These symptoms continued up to the period of admission. He left Leeds, where he was first attacked, and went to York and Newcastle, whence he came by sea to Edinburgh, eight days ago. Since then there has been some oedema of the legs. Symptoms on Admission.—Tongue clean, fissured transversly, bad taste in the mouth. No appetite; thirst. The epigastrium is swollen; tympanitic on percussion, and very painful on pressure. Lateral hepatic dulness 6 inches vertically. The lower border of the organ may be felt 2 inches below the ribs, which bulge very much on the right. Splenic dulness normal. Bowels moved from three to seven times a day. Stools are slimy and contain no blood. No dyspnoea. Slight cough, with scanty expectoration. On right side anteriorly from clavicle to nipple vocal resonance and thrill much increased. Percussion and breath sounds normal. Below the line of the nipple absolute dulness, and complete absence of breath sounds and vocal resonance. Posteriorly, from the level of a transverse line passing 2J inches below the spine of the scapula downwards, there exists complete dulness on percussion, with absence of respiratory murmurs. Percussion over this area causes great pain. Above this line vocal resonance is bronchophonic. The left side of chest is normal. No friction sounds audible either before or behind. Heart healthy. Pulse 108, weak. Both legs are slightly cedematous below the knee. Patient sleeps badly at night, and feels very weak. Urine normal in color; no albumen; density 1015. R Tr. Catechu §j; Misturam Cretm ad % vi, misce. A tablespoonful thrice a day. Progress op the Case.—Nov. 8th.—Friction heard on right side immediately above the nipple ; none behind. Copious deposits of urates in urine. R Spt. ^Eth. Nit. 3 ii; Sol. Amm. Acetatis % ss; Aquam ad § vi, M. A tablespoonful four times a day. Nov. 9th.—Friction heard more distinctly at 6ame spot. Otherwise as yester- day. Hot poultices to be applied orer the affected side. Nov. 10th.—Distinct segophony heard on the right side posteriorly. Urine clear; pulse soft. Nov. 12th—At evening visit last night, patient complained of excruciating pain in the right side. To have 3 ss of chlorodyne. Slept well last night and feels refreshed to-day; pain in the side less severe. Friction and aegophony persist. Hot poultices to be continued at intervals. Nov. 15th.—Slight friction heard over the third right costal cartilage. Above this, increased vocal resonance and harsh breathing. The pain is nearly as great as formerly. ^Egophony still audible. Thirst is excessive; tongue parched and cracked. Pulse 96, soft and weak. Diarrhoea is now reduced to two evacuations per diem. To have wine § iv, and nutrients. Nov. 11th.—Diarrhoea continues. Pulse 110, weak. Pain in upper part of abdomen and the right side still excessive. The poultices afford only slight relief. To resume his chalk and catechu mixture, which he had discontinued for a day or two. Nov. 20th.—Slept better last night than for some time past. No friction audible, and segophony completely gone. Nov. 22d.—This evening he coughed up about 12 ounces of a reddish grumous matter. Nov. 23d.—Friction again heard on the right front, mixed with crepitation accompanying inspiration. Pulse 106, soft and weak. Copious expectoration of the thick red fluid continues, which under the microscope is composed of blood and pus corpuscles, with numerous molecules and granules. Nov. 26th.—On right side of chest, both in front and behind, there is now complete dulness and absence of vocal resonance and thrill. Breathing distant and tubular. Pulse weak. Tongue pale moist and furrowed. Nov. 21th.— Pulmonary signs as yesterday. Tongue dry! Copious bloody expectoration continues. Delirious last night. Pulse very weak. * Recorded by Mr. J. S. Torrop, Clinical Clerk. " 502 DISEASES OF THE DIGESTIVE SYSTEM. Nov. 28th.—K tympanitic sound elicited on percussion over an area about the breadth of a crown-piece, immediately under the right clavicle. Nov. 29th.—The tympanitic sound has extended lower down to-day. Pulse exceedingly weak. Diarrhoea has ceased, and oedema of the legs disappeared. Urine is slightly albuminous. De- cember 2d.—Tympanitic note audible over the right front to a distance of three inches below the right clavicle. Over this area there is heard distant tubular breathing. No moist sounds on left front or back. Patient sleeps very badly at night, but has now no delirium, diarrhoea has returned, three stools daily. The right leg and arm have become partly cedematous. Urine still slightly albuminous. Continues to expectorate bloody sputum. Pulse almost imperceptible. Gradually sank, and died on the 5th at 4 a.m. Sectio Cadaveris.—Thirty-three hours after death. Thorax.—On opening the right pleural cavity, a quantity of air escaped, and bloody pus welled out. It contained about four pints of fluid. Above, the right lung was compressed and coated with lymph. Below, it was adherent to the diaphragm, infiltrated with bloody pus to the extent of one-fourth of the lower lobe, and com- municated with the pleural cavity by a gangrenous perforation. Left lung slightly congested. The pericardium contained a little clear serum. Heart healthy. Abdomen.—The liver was much enlarged, and adherent to the diaphragm. In the substance of its right lobe was a cavity of about the size of a large cocoa-nut, full of pus and blood and partially disintegrated hepatic substance. It was traversed diago- nally by a bridge of hepatic substance, about half an inch thick, broken down in the centre, as if the excavation had been formed by the union of two separate abscesses. It communicated with the substance of the lung, and with the pleural cavity by a perforation through the diaphragm, which readily admitted two fingers. It also com- municated with an abscess situated between the liver and diaphragm, and with another situated in the retro-peritoneal cellular tissue of the right side. This abscess had penetrated as far as the upper and posterior margin of the kidney, and had caused ulceration in a small portion of its cortical substance externally. The wall of the hepatic abscess was composed of indurated substance, three-quarters of an inch thick, and of a fawn color, passing gradually into the healthy hepatic tissue. No trace of echinococci could be found. The spleen was large, and weighed 13 ounces; waxy. The gall bladder contained a large quantity of pale yellow bile. Other organs were normal. Microscopic Examination.—The contents of the hepatic abscess consisted of pus and hepatic tissue in a state of fatty disintegration. The thickened hepatic wall con- sisted of molecular fibres densely aggregated together, in which no trace of cell-struc- ture could be discovered. Commentary.—The indurated wall of the hepatic abscess in this case is sufiicient to prove that it is one of those instances where the disease had progressed slowly for some time, and was very chronic, while the history shows it was not accompanied by any symptoms. The sudden commencement of severe abdominal pain three weeks before admission, accompanied by fever, probably indicated bursting of the hepatic abscess into the retro-peritoneal cellular tissue. The communication with the right thoracic cavity was probably made shortly before admission, and continued to extend until the 22d of November, when a perforation into the lung having been effected, matter in considerable quantity passed through the bronchi and was expectorated. Abscess of the liver is a very rare disease in Edinburgh, and the pre- sent case, in which it burst first into the retro-peritoneal cellular tissue, then into the cavity of the pleura, and lastly into the lung and bronchi, exhibits unusual features. One other such case is recorded by Waring. For the various modes, however, in which the disease may terminate, with the tabular results of the cases collected by Rouis, Morehead, Waring, and others, I must refer to the excellent translation of Frerichs on the Liver, by Dr. Murchison, vol. ii. I have never had an oppor- DISEASES OF THE LIVER. 503 tunity of examining suppurative inflammation of the liver in an early stage, nor is much known of the histological changes which precede the formation of pus in that organ. Virchow supposes that new growths in the liver originate in the multiplication of its cells, and has supported his theory by supposititious diagrams (" Cellular Pathology," p. 65). It is not, however, in this way that pathological difficulties can be solved. In a paper I received from Dr. Macnamara, extracted from the Indian Annals of Medicine (date not stated), he alludes to the frequency of abscesses of the liver following dysentery, and says:—" The most pro- minent microscopic change I have been able to discover in the dysen- teric liver is a granular degeneration of the cells, attended in the more advanced stage with a deposition of intercellular granular matter. This granular change may be equally present in livers in which abscesses have formed, and in those in which there are no indications of them. The cells undergoing this degeneration often look scaly, and their edges are generally ragged and disintegrated. Some cells look in fact like a mere aggregation of fine granular matter held together by the cohesion of the particles, and not at all sustained by any cell wall. In other cells, not so advanced in degeneration, the cell wall and the nucleus may be detected, but the latter looking as if choked by the quantity of granular substance deposited about it. In many cells the most careful examination has failed to show me any nucleus. I have on three or four occasions, when examining these disintegrating cells, observed that they appeared set, I might almost say scattered, in a granular matrix, which has seemed in more than one instance to have a semifibrillated structure. Such a precipitate of albuminous molecular matter both inter- and intra-cellular may arise from repeated attacks of slight congestion of the liver, or from a long-continued engorgement of the organ." From this account it would appear that in this, as in all other inflammations, the essential primary change is the exudation of a molecular matter, which is intercellular, and out of which, doubtless, the pus cells are formed, although Dr. Macnamara does not clearly state this. The three forms of abscess in the liver, viz., circumscribed, diffuse, and secondary, are admirably figured in the great work of Cruvelhier. In the examination of dead bodies, I have frequently seen in the liver indurated masses, accompanied by puckerings or cicatrices of the surface. Not unfrequently they have undergone the calcareous trans- formation to a greater or less extent. They are evidence of previous exudations, which, instead of proceeding to the formation of abscesses, have been arrested, the animal matter absorbed, the whole condensed and hardened. Such masses I have seen associated with simple or inflam- matory, with tubercular, or with cancerous exudations. (On Cancerous and Cancroid Growths, 1848.) Dittrichwas the first to regard them as syphilitic (1849), and several pathologists following him have spoken of them as syphilitic deposits. It is of course easy to associate a chronic lesion of this kind, with a disorder so widely diffused as syphilis, for the simple reason that among the multitude of persons affected with the lat- ter, a considerable number after death are certain to present the former. I have frequently seen them, however, in persons who never had syphilis, and consider that all that can be maintained correctly with regard to them is, that they are the remains of chronic exudations into the organ, 504 DISEASES OF THE DIGESTIVE SYSTEM. which have spontaneously healed. We find similar morbid products in the lungs, kidneys, and lymphatic glands, and not only is there no necessity for associating them with a supposed dyscrasia, but manifest injury might arise. The honor and feelings of relatives, for example, might suffer by assuming that because a nodule of indurated matter with puckering was found after death in a person's liver, that therefore such individual, male or female, must have been previously suffering from syphilitic disease. It is erroneous generalizations of this kind that tend so much to bring discredit on our science in courts of law. What mis- chief has arisen from the idea that a corpus luteum of a certain form or appearance, must have been connected with conception, or the delivery of a child. Would it be maintained for a moment, if, in the body of a virtuous lady of high rank, an indurated mass of exudation, with puckering, was found after death, that this had been caused by the syphilitic disease? All such pathological generalizations cannot be received with too much caution, especially when we see, as in the case before us, to what extent chronic hepatitis may proceed without giving rise to any symptoms, while there can be little doubt that others are arrested in an earlier stage, and thus give origin to the nodules and cica- trices so frequently found in the liver after death. Frerichs regards waxy degeneration of the liver as a result of syphilis, with which, however, it has no more special connection than any other lesion of that organ. Case LXXIL*—Impaction of a Gall-Stone in the Common Bile-Duct— Atrophy of the Substance of the Liver—Jaundice—Death. History.—Mary Duncan, set. 36, married—admitted November 24, 1851. She has lived in India for some time, and returned only a few months since. Three weeks ago, when recovering from a severe attack of lumbago, she experienced great pain in the epigastric and right hypochondriac regions. This was ushered in by rigors and feverishness, and lasted three or four days. Its severity then diminished; but jaundice appeared, and has since become more intense. Symptoms on Admission.—On admission, the whole integumentary surface pre- sented a deep yellow color. Pulse 100, full. The tongue is dry, with a dark brown coat. There is a disagreeable taste in the mouth, impairment of appetite, but no nausea or sickness. The liver on percussion presents the normal dulness of four inches on the right side. Pressure in the neighborhood of the gall-bladder elicits pain, and there is permanent soreness diffused over the anterior portion of the liver and epigastric region. The pain is not spasmodic in its character, nor more severe at one time than at another. The bowels are generally costive; skin hot and dry, urine like porter, staining linen yellow, and becoming green and then red on the addition of nitric acid. The abdomen is enlarged. She has had a child previously, and says she is now six or seven months pregnant. The treatment consisted of purgatives {PU. Rhei. comp.) ; leeches and fomentations to the tender spot over the liver, and diuretics of acetate of potass and sp. azther. nit. Progress op the Case.—December 3d.—The bowels have been kept open by purgatives, and the stools have been well colored with bile. Leeches have been applied twice, and the hepatic pain has been much relieved. She has also been taking small doses of tartrate of antimony, and muriate of morphia. The skin, how- ever, continues dry, and is now more deeply tinged yellow than on her admission. The urine also is still loaded with bile. To-day vomiting came on, and she com- plains of great languor and depression. Diuretics to be continued; a blister to the right hypochondriac region ; and a powder, containing four grains of calomel and one- third of a grain of opium, to be taken every hour for six doses. The mercury produced no physiological action, although continued in smaller doses and at longer intervals for several days, assisted by mercurial frictions over the right hypochondrium. * Reported by Mr. J. L. Brown, Clinical Clerk. DISEASES OF THE LIVER. 505 Dec llfc-There was slight diarrhoea, which was checked by an aromatic cretaceous mixture. Mercurials were suspended. On the 13lh she was evidently worse; the skin assumed a greenish hue; she is very feeble, and passes her stools in bed; pulse im, small On the 15th the skin assumed a tawny color; the stools are passed in bed, are green of a dark color, and of a very offensive cadaveric smell; great prostration ot strength; urine still loaded with bile; low delirium at night. Died on the IMA. Sectio Cadaveris.—Thirty hours after death. Thorax.—Thoracic organs healthy. Abdomen.—On opening the abdomen, bands of recently-exuded lymph are found firmly uniting together the peritoneal surfaces of the gall-bladder the anterior margin of the fiver, and a portion of the omentum, over an extent the size of the palm of the hand. On separating these adhesions, the gall-bladder and omentum were found so firmly united, that an aperture was formed in the former the size ot a pea, through which a quantity of dark-green bile escaped. The liver was ot its normal size, and presented externally a dark olive-green color. On cutting into its substance, the gall-ducts were everywhere dilated and thickened. Some were distended into elongated cavities above half an inch in calibre, and they were all filled with thick dark-green bile. The tissue of the liver throughout was unusually soft, readily breaking down under the fingers, and uniformly of the same olive-green color as the external surface. In the common bile-duct, about half an inch from its duodenal extremity, a hard light-yellow gall-stone, the size of a small hazel-nut, was firmly impacted, the duct both above and below being somewhat thickened and dilated. No other gall-stones could be anywhere discovered. The uterus and rec- tum were adherent, and in separating them about a teaspoonful of yellow pus escaped. The vagina was shortened and constricted about two inches from the vulva, so as scarcely to admit a common quill. About an inch width in the vagina, on its inferior wall, was a round aperture, the size of a shilling-piece, with ragged edges, and communicating with the rectum. On the superior wall of the vagina, about half an inch from the clitoris, was another rounded opening, about the size of a sixpenny-piece, into which the point of the little finger could be pushed and passed into the bladder. The natural meatus urinarius was occluded. Microscopic Examination.—On crushing a small piece of the liver between glasses, and examining it under a power of 250 diameters linear, it was found to consist of a multitude of fatty molecules and granules, with larger ^ft '££ globules of loose oil. Many of the cells seemed to be broken down and disintegrated, but such as were entire were more or less distended with bile pigment.—(Fig. 424.) Commentary.—The symptoms present in this case on admission—viz., the jaundice, local pain, the rigors, and fever—were indicative of obstruc- tion in the common bile-duct connected with some inflammatory action going on in the liver or its neighborhood. Hence the topical applica- tion of leeches, and afterwards warm fomentations, were ordered. As the blood and urine were evidently loaded with bile, diuretics and pur- gatives were also given to assist the excretion of that product. These remedies proving of no avail, and the constitutional symptoms increasing, mercury, conjoined with opium, was actively administered, but failed to produce its physiological or any useful therapeutical result. After death, peritonitis surrounding the gall-bladder and common duct was dis- covered ; but death evidently resulted from the poisoning of the system through the absorption of bile, the excretion of which was prevented by the firm impaction of a calculus in the common bile-duct. The benefit of mercury in such cases, though strongly recommended as a means of altering the constitution of the bile, appears to me very doubtful, for, Fig. 424. Disintegration of the hepatic structure following obstruction of the biliary ducts. 250 diam. 506 DISEASES OF THE DIGESTIVE SYSTEM. supposing it to possess the effect ascribed to it, and to act as an altera- tive and cholagogue, its action in obstruction of the gall-ducts must be to distend them still further, and thus increase the pressure on the hepatic cells, and consequently the disintegration of the hepatic texture. Most of the examining class were in favor of the trial of mercury in this case; and considering how uniformly it has hitherto been recommended by experienced practitioners, I did not think it right to deprive the patient of any chance which might arise from its use. At the time, I expressed my want of confidence in its virtues, an opinion which the progress of the case fully justified. In the present state of science and art of medicine, there is no one point in therapeutics which so urgently requires thorough re-investigation as the real value of the medical pro- perties attributed to mercury. I have tried podophyllin as a purgative in many cases, and found its action to be very uncertain, sometimes purging in one, at others requiring seven grain doses. It seems to have no power whatever as a cholagogue. In this case there was a partial disintegration of the cell elements of the liver, and an accumulation of bile in such of the cells as remained perfect. This lesion is remarkably well described by Dr. Budd, in the third chapter of his work, where he treats of fatal jaundice. It admits of question, how far this destruction of the hepatic cells may not, by impeding the secreting power of the organ, at length induce that condition described by Dr. Alison, where the biliary principles are not eliminated. It must, I think, be certain that jaundice, produced primarily, as in the present instance, by a mechanical obstruction, must be kept up by this altered condition of the cell-structure. The same disintegrated structure of the liver, occurring either with or without obstructive lesion, constitutes what Frerichs calls acute atrophy of the organ. This case was instructive to all who observed it, with regard to a supposed pregnancy she labored under. The abdomen was certainly somewhat prominent; but the investigation of the existence of this state was never gone into, for the simple reason, that it no way affected the diagnosis or treatment. When the woman was dying, however, the hus- band applied to me, with a view of ascertaining whether it might not be possible to save the child. On this point I requested the opinion of Dr. Simpson, who, on examining the woman, declared her not to be pregnant. This circumstance, then, is an illustration of how women who have pre- viously had children may be deceived as to the existence of a subsequent pregnancy, and how important it may be for the practitioner to satisfy himself of the reality or falsity of such a state. When formerly delivered in India, she said instruments were employed, and that she sustained some injury. This account is rendered highly probable by the existence of the recto-vaginal and urethro-vaginal fistulge, and the remarkable vaginal stricture found after death. Case LXXIII.*—Jaundice—Compression of the Ductus Communis Chole- dochus from a Cancerous Tumor, composed of Epigastric and Lumbar Glands—Occlusion of Cystic Duct—Enlargement of Gall Bladder— Cancer of the Pancreas—Biliary Congestion of the Liver— Cancerous Exudation into various organs—Slight Leucocythemia. History.—William Dodds, set. 23, ploughman—admitted December 8th, 1854. * Reported by Mr. Robert Rhind, Clinical Clerk. DISEASES OF THE LIVER. 507 He states that four weeks ago he was seized with pain in the lower part of the ab- domen, accompanied by unusual costiveness. Some days afterwards he commenced to vomit his food a few hours after taking it. The vomiting continued tor a tort- night, and then suddenly ceased. But it returned about four days ago as betore, and has continued up to the time of admisssion. Symptoms on Admission.—The tongue is loaded with a thick white coat, but moist. Appetite bad. After taking food be has a feeling of great load and disten- sion in his stomach. No flatulence, but has frequent eructations of a watery fluid, which is neither acid nor of disagreeable taste. Usually vomits it about four o clock a. m, and for some time afterwards experiences considerable relief; has constant severe pain and considerable tenderness over the epigastrium. A tumor can be felt towards the pyloric end of the stomach, of a rounded form. It measures two and a half inches vertically, its upper and lower margins being distinctly tangible. Its lateral margins, however, cannot be determined. The hepatic dulness in the right hypochondrium was normal. All the other functions are healthy. Diet to be care- fully regulated. Progress op the Case.—December 10th.—Has been much better since admission, not having vomited till this morning at five o'clock. , He then brought up a large quantity of brownish pultaceous matter, which, on microscopic observation, was found to consist of half-digested muscular fibres, starch and oil globules, and epithe- lial cells. Has considerable pain and tenderness in the epigastrium. Eight leeches to be applied, followed by warm fomentations. Dec. 18th—There have been remissions in the epigastric pain, which, however, still continues. The vomiting also has not been permanent, having been suspended for two days by eating ice, and again on the 16th, by a morphia draught. The constipation has been relieved by domestic ene- mata. It was observed to-day, for the first time, that the skin has a decided though very slight yellow tinge. Dec. 23d.—Since last report has experienced great pain at times in the abdomen generally, for which he was ordered a draught at night with Tr. Cannabis Ind.; 3ss. Six more leeches were also applied on the 20th, but with- out lessening his sufferings. There has been considerable fever with thirst and los3 of appetite. Iced lemonade for drink, and warm fomentations to the abdomen, give most relief. Yesterday the jaundice was decidedly more pronounced, and has increased still more to-day. There has latterly been constant vomiting, shortly after taking food. He is more emaciated, and the tumor formerly alluded to can now be felt hard and nodulated through the integuments. The stools are of a clay color, and the urine loaded with bile, so as to resemble porter. Pulse 120, very weak. R PU. Opii vj. One to be taken immediately, and repeated in four hours if there be no alleviation of the pain. To have wine §iv daily, and ice to dissolve in the mouth. Continue the warm fomentations to the abdomen, and to inject slowly § iv of strong beef tea into the rectum. From this time he continued sinking. The skin assumed a greenish tinge. On the 24th he vomited blood, and passed black tarry matter by stool. Brandy and stimulants were freely administered, but he died Dec. 26th. Sectio Cadaveris—Fifty-one hours after death. The body considerably emaciated. The whole surface of all the tissues, includ- ing the cartilages, were stained of a greenish-yellow color. Thorax.—Both lungs were emphysematous anteriorly, especially the left. Pos- teriorly they were engorged, and on section were cedematous, with scattered nodules of cancerous matter in their substance, of cheesy consistence, but occasionally very Boft, and varying in size from a pepper-corn to that of a small hazel-nut. A con- tinuous layer of cancerous matter also here and there surrounded the bronchial tubes. From the universal predominance of bile-pigment, these cancerous masses closely resembled to the eye tubercular matter. Immediately under the upper part of the sternum, and over the ascending aorta, was a mass of lymphatic glands, about three inches long and two inches thick, of a fleshy color and pulpy consistence, easily breaking down under the finger, and infiltrated here and there with a yellowish- white cheesy deposit, exactly resembling tubercle. The bronchial glands at the root of the lungs were greatly enlarged, and presented a similar appearance. The heart was healthy. The ventricles contained semi-coagulated blood, the veins black fluid blood. Abdomen.—In the cavity of the peritoneum there was about 8 oz. of dark- brown clear serum. The liver weighed 3 lb. 12 oz., was of a light olive-green color, approaching to brown, soft in texture, and on section was seen to contain a few 508 DISEASES OF THE DIGESTIVE SYSTEM. whitish-yellow masses, varying in size from a millet-seed to that of a small pea, of tolerably firm consistence. The gall-bladder projected about an inch and a half below the lower margin of the liver. It was considerably enlarged, and was distended with thick black bile. The cystic duct was completely closed a little above its junc- tion with the hepatic, which was quite free. The calibre of the common duct was much diminished; and although a probe could be pushed through it, it was evidently compressed by the tumor to be described immediately. The spleen weighed 5 oz., and was healthy, with the exception of a cancerous mass in its centre, about the size of a coffee-bean, similar to those in the lung. Surrounding the pyloric end of the stomach, and projecting from below the liver towards the left side, was an agglome- rated, indurated, and nodulated mass of enlarged and cancerous lymphatic glands, of the size and form of a cocoa-nut. This was the tumor which, during the life of the individual, was felt in the epigastrium. It pressed upon and completely occluded the ductus communis choledochus. The aorta passed through the left third of this mass, and was so compressed as scarcely to admit the little finger. On section, this mass presented very much the appearance of some specimens of pudding stone, con- sisting of rounded or oval yellowish-white masses, varying in diameter from £ to 1| inches, and united together by highly congested areolar tissue, of a deep purple color, with here and there extravasations of blood in its substance. The affected glands were friable and easily crushed between the fingers, but yielded no juice on pressure. The mesenteric, mesocolic, and lumbar glands generally, were similarly diseased. The right extremity of the pancreas was converted into a firm mass by cancerous exudation, and closely connected to the tumor just described, of which it formed an integral part. On opening the stomach, it was seen to contain a quantity of tenacious, brown, glairy mucus, closely coherent to the mucous membrane. Its walls at the pylorus were found thickened; and from this point the thickening gra- dually diminished, until it ceased at a convex margin, somewhat irregulrrly nodulated, and elevated above the rest of the mucous surface. The diseased portion occupied about one-third of the area of the organ. The mucous surface covering it was of a dirty-white color, and was ulcerated at one point with softened ragged edges over a space the size of a shilling-piece. The healthy two-thirds of the mucous surface was of bright rose-pink color, from vascular congestion. The cut edge of the pylorus was a quarter of an inch thick, dependent on hypertrophy of the muscular coat to the extent of one-sixth of an inch, and of an infiltration of firm whitish exudation, in the submucous areolar tissue. The intestines, kidneys, and other organs, were healthy. Microscopic Examination.—The whitish-yellow masses in the lungs were prin- cipally composed of molecular matter, but with numerous delicate nucleated cells apparently forming. In the bronchial glands, the whitish-yellow matter was com- posed of a few cancer cells only, evidently in a state of disintegration, associated with multitudes of fatty molecules and granules. The fluid squeezed from the fleshy and pulpy matter from the same glands, contained, 1st, numerous round and oval nucleated cells, about one-thousandth of an inch in diameter ; 2d, many granule cells of varying size; 3d, multitudes of gland nuclei; 4th, blood corpuscles; 5th, a large quantity of molecular matter. The pulp of the epigastric glands contained, 1st, large cancer cells, soifie containing three included cells; 2d a very few granule cells; 3d, numerous molecules. The blood contained a decided increase of colorless corpuscles. The cells of the liver contained a quantity of biliary matter, giving them, under the micro- scope, a bright yellow color. Commentary.—The nature of this case was tolerably evident from the first; the epigastric tumor, pain, and vomiting after taking food, indicated obstruction of the pylorus produced by a cancerous growth. Later, when jaundice appeared, it became clear that the common duct was obstructed. Treatment could, of course, only be palliative. On dissection, it was singular to observe the resemblance which the can- cerous masses in the lungs and in the glands bore to tubercle. Some persons who were present, indeed, judging from the youth of the patient, their friable consistence and yellow color, maintained that the glands were scrofulous, and it would have been difficult to undeceive them without the assistance of the microscope. All the tissues were tinged of a deep yellow, and the hepatic cells were gorged with bile, so that the DISEASES OF THE LIVER. 503 absorption of this excretion into the blood must have been very great. The insensible manner in which so much cancerous matter developed itself is worthy of observation, as it was only four weeks before admis- sion that he experienced any inconvenience. Then came on the effects of obstruction—first, of the pylorus, and, secondly, of the common duct— from the combined effects of which he died. Case LXXIV.*—Jaundice—Cancerous Tumor of the Pancreas, com- prising the Ductus Communis Choledochus—Dilatation of the Gall- bladder, and passage of Gall-stones into the Gall-bladder—Cancer of the Liver and Kidneys. History.—John M'Donald, set. 50, tailor—admitted November 29, 1853. Four weeks ago he was seized with a gnawing pain in the epigastrium. On the 13th he was over-worked, and went home much exhausted. On the following day, there was drowsiness, loss of appetite, and anorexia. On the 27th, the skin was slightly tinged yellow. He applied at one of the dispensaries, and was then suffering from intense grinding pain in the right hypochondrium. One of the clinical students who saw him there advised him to come into the Infirmary. Symptoms on Admission.—He has no pain, no difficulty in taking food, though it excites nausea. Tongue slightly furred; moist. No appetite. Considerable thirst. Vertical dulness of liver is 3f inches. No abdominal tenderness. No tumor to be felt in epigastrium. Bowels constipated. Stools of a dark green color; but he says they were white when the attack came on. Urine is of a dark brown color, like weak porter, from the presence of bile; unaffected by heat. Pulse 60, regular. Skin of a deep yellow color. Other organs and functions normal. R PU. Hydrarg.; PU. Rhei Co. aa 3 ss. M. et divide in pil. xii. Two to be taken every night. Progress op the Case.—December 3d.—The stools are now of a lead color. To have gr. v. of Pil. Hydrarg., and of Ext. Taraxaci every night. Dec. 10th.—Com- plains of acute grinding pain in the region of the liver. Bowels have not been open for some days. Skin of a deeper yellow. To have gr. v. of Pil. Rhei Co. in addUion to the others. Dec. 12th.—Had an assafoetida enema yesterday. The bowels have been well opened; pain much relieved. Stools still of a lead color. Omitiant. PU. R PU. Rhei Co. 3 j; Calomel. 3j ; Olei Cinnamomi guttas iv. M. et divide in pil. xij. Two to be taken every night. Dec. 14th.—Is now free from pain, but feels very weak. Stools of a dark green color. Otherwise the same. Cannot take food. R Liq. Potassa; 3 ij ; Sp. jEther. NU. § ss; Infus. Gentian. Co., % v. M. Two table- spoonsful to be taken three times a day. Dec. 11th.—Much weaker. Takes no nourish- ment. Skin of a dark green tint. Tongue dry, and covered with a dark brown crust. Bowels open. Stools of a dark leaden tint. Pulse 120, very weak. To have § vj of wine. Dec. 19th.—Whisky has been liberally administered; but he continued to sink, and died at two o'clock a.m. Sectio Cadaveris.— Thirty-four hours after death. Extreme jaundiced appearance of the whole body, and yellowness of all the tissues. Thorax.—With the exception of slight emphysema of the lungs, all the thoracic organs were healthy. Abdomen.—On opening the duodenum, there was seen at the point where the com- mon duct enters it, a tumor bulging inwards, and compressing the duct. The growth was the size of a walnut, and presented all the characters of scirrhus. It was formed in the right extremity of the pancreas; and the rest of the organ was indurated, and contained several small cysts filled with a gelatinous fluid. The portion of the com- mon duct which passed through the tumor was an inch and a half long, and barely admitted a small probe. Behind the constriction, the common, cystic, and hepatic ducts were greatly enlarged, the common duct having a calibre nearly equal to the size of the thumb. The gall-bladder was much enlarged, and distended with dark- colored bile. It contained two small gall-stones of bile pigment, but none could be found in the ducts. The liver weighed 3 lbs. 9 oz., was of a green coJor, with the centres of the lobules congested. The bile-ducts were everywhere dilated throughout its substance. Scattered throughout the liver were white cancerous masses varying * Reported by Mr. Almeric Seymour, Clinical Clerk. 510 DISEASES OF THE DIGESTIVE SYSTEM. in size from a pea to that of a hazel-nut. Similar small cancerous masses existed in the cortical substance of the kidneys. On opening the intestines, a considerable quantity of black blood was found mingled with the faeculent matter, both in the small and large intestines. Other organs healthy. Microscopic Examination.—The cancerous masses in the pancreas, and liver, and kidneys, contained numerous characteristic cells. The hepatic cells were loaded with yellow bile, which became of a cherry-red color on the application of Petten- kofer's test. They contained no fat. Commentary.—It appeared, from careful examination of this man's case, that he had suffered from two attacks of grinding pain in the right hypochondrium, such as are commonly felt during the passage of gall- stones. After death, two biliary calculi were found in the gall-bladder, having all the appearance of those which are usually formed in the liver. It is almost certain, therefore, that the painful attacks were coincident with the passage of these calculi from the liver to the gall-bladder, as their escape into the intestines was prevented by the constriction of the common duct, by the cancerous mass in the pancreas. Since the researches of Bernard as to the functions of the pancreas were made known, I have carefully sought, in a great number of cases, for the passage of fatty matter in the alvine evacuations, but in vain. In several instances of jaundice, such as the present, I have found the head of the pancreas diseased; but in none of them did the stools present the characters described in the cases of Bright, Lloyd, Elliotson, and others. It is true that in this case the common duct was not absolutely obliterat- ed, but it appeared to me that the pancreatic duct was so involved in the tumor, that its fluid secretion was incapable of passing. But as no special anatomical investigation was made in reference to this point, we are not entitled to suppose that the supply of pancreatic juice was entire- ly cut off. In other cases, however, where the common duct has been ob- structed (Case LXXIL), or where, from disease of the head of the pancreas, the pancreatic duct hasbeen obliterated (Cases LXIV. and LXXIII.),there has been no proof whatever that the fatty elements of the food have not been emulsionized. Such facts indicate that the function attributed by Bernard to the pancreas must also be performed, under certain circum- stances by the alimentary canal alone, independent of that organ. Case LXXV.*—Enlargement of the Liver—Ascites—Albuminuria— Recovery. History.—David Harper, set. 30, painter—admitted into the clinical ward Febru- ary 18th, 1852. Four months ago, was seized with diarrhoea and vomiting, which have continued more or less ever since. The liver was first observed to be enlarged in the beginning of December last, and it has gradually increased in size up to the present time. He has taken numerous remedies to check the diarrhoea and vomiting, but with little effect. Symptoms on Admission.—On admission, the liver is found to extend from one inch below the right nipple above to within an inch and a half of the anterior supe- rior spine of the ilium below—a depth of nine inches. From this point its margin could be felt ascending obliquely upwards to the most depending portion of the ninth rib on the left side, crossing about an inch above the umbilicus. There is distinct fluctuation to be felt throughout the rest of the abdomen, indicating ascites. In the right lumbar region the enlarged liver is tender on pressure. The abdomen measures 42-J inches in circumference at its widest part. Spleen of normal size. Tongue moist, slightly loaded. There has been no vomiting for some days, but the diarrhoea is very severe. Says he has frequently passed blood by stool. Skin not jaundiced, * Reported by Mr. J. A. Douglas, Clinical Clerk. DISEASES OF THE LIVER. 511 but rather dry. Respiratory, circulatory, and other systems normal. R Pil. Plumb. et Opii xij. Sumat unam ter indies. Progress op the Case.—March 4th.—Has had occasionally vomiting and diar- rhoea since last report, for which he has been taking at times the naphtha mixture, morphia draughts, and gallic acid. To-day the urine is somewhat scanty, and slightly coagulable on the addition of heat and nitric acid; spec. grav. 1024. R Acetatis Potassa 3 j ; Sp. uEth. Nit. 3 ij ; Syr. Aurantii § j ; Aqum § v. M. Sumat 3 j ter indies. March 12th.—To-day the urine was ascertained with the microscope to contain numerous casts of the tubes and isolated epithelial cells loaded with fatty granules. The vomiting and diarrhoea continue. Habeat suppositorium opiatum octavd qudque hord. April 6th.—The diarrhoea was for a few days somewhat checked by the suppositories, but gradually returned, and is now very severe; the bowels having been opened twelve times yesterday. The urine has continued albuminous, and loaded with desquamative casts and fatty tubes. To-day its spec. grav. is 1007. There is now great debility, and occasional stupor and drowsiness. May 12th.—The drowsiness has disappeared. For the last few days has been taking 3 j of the potass. bitart. with the mixture of acetate of potash and nitric ether, and he now passes a larger amount of urine, which is free of tubular casts. The abdomen is less tense. About the middle of May the vomiting and diarrhoea first abated, and was soon after checked. In August his health was so much improved that he was allowed to go out of the house for the benefit of air and exercise. He was readmitted September 13th, having enjoyed tolerable health in the interval, although the hepatic swelling is about the same size. He was now ordered, R Hydrarg. Proto-iodidi, gr. vj; Pulv. Opii gr. ij; Ext. Taraxaci 3 ss; Conserv. Rosarum gr. v. Fiant pU. xx. Sumat unam ter indies. These pills on the 20th produced salivation, when they were dis- continued, and an astringent gargle was ordered. The abdomen now measures thirty six inches in its broadest circumference. Oct. 25th.—Complains of oppression on walking, of shooting pains through the chest and abdomen. Ascites seems once more to be increasing. Tr. lodinei to be painted over the abdominal surface. Nov. 21st.—Since last report the liver has greatly diminished in size, and his complaints have ceased. The urine presents a slight hazy albuminous appearance on the addi- tion of heat and nitric acid, but is voided in natural quantity. Dec. 13th.—The liver is now so reduced in size that its lower margin is only two inches below the false ribs in front, and one inch on the right side. All his functions are apparently healthy, the urine healthy, and his strength appears perfectly re-established. Dismissed. Commentary.—The enlargement of the liver which existed in this man was probably simple hypertrophy, which, by pressing upon the large abdominal veins, caused ascites. It is worthy of remark, that it underwent a sensible diminution after the local application of Tr. of Iodine, having resisted mercurial action and various other remedies. The occurrence of Bright's disease, and the presence of numerous desqua- mative casts of the tubuli uriniferi, more or less loaded with fat, and of albumen in, with diminished density of, the urine, were considered for- midable complications. But here, also, under the use of strong diuretics, the renal symptoms subsided, the casts disappeared, and the urine be- came perfectly healthy. He has since been seen by the clerks walking about the town, and informed them that he is quite well, and carries on his occupation without any inconvenience. Case LXXVL*—Fatty Enlargement of the Liver. History.—James Grant, aet. 29, blacksmith—admitted October 14th, 1851. His occupation consists of watching an apparatus worked by steam, in a room of elevated temperature; he has no heavy labor, though constantly standing on his feet; he drm^s whisky to a large amount. Since September 1849, he has been three times in the house for various periods, from which he has been as often dismissed relieved. the fiver began to enlarge two years ago, and has been very slowly increasing ever since. j j o Symptoms on Admission.—On admission, he labors under slight diarrhoea, hav- * Reported by Mr. W. M. Calder, Clinical Clerk. 512 DISEASES OF THE DIGESTIVE SYSTEM. ing had two or three stools daily for several weeks past. He has, moreover, a dull heavy pain in the abdomen, extending to the lumbar region. The belly is evidently enlarged at its upper part, where a firm tumor exists, forming a protuberance in the epigastric region. The girth of the abdomen at this place during expiration is 34 inches. The hepatic dulness extends from two inches below the right nipple down to a transverse line drawn one inch above the superior spine of the ilium. The whole of the right and part of the left hypochondriac regions are dull on percussion. The tym- panitic sound of the stomach is audible in front, the organ being evidently pushed forward by the enlarged liver behind it. The whole surface of the tumor feels smooth, and presents no tenderness. The splenic dulness measures 5£ inches verti- cally ; skin dry: no oedema of the legs; general appearance pale and cachectic; occa- sionally he has frequent desire to micturate, but the urine has always presented its normal characters; considerable breathlessness on exertion, but the lungs and heart, on examination, were apparently quite healthy; other functions well performed. He was ordered a mixture containing the Iodide of Potassium, six grains of which were to be taken three times a day. Frictions with the Unguent. Iodinei were also to be employed daily. Progress of the Case.—Towards the end of October, the bowels became regular, and his general health was somewhat improved. Frequent micturition, with discharge of pus in the urine now came on, which subsided in a few days. From this time, although the size of the liver underwent no diminution, his bodily strength gradually improved. He occasionally had slight return of looseness in the bowels, which was checked by appropriate remedies. The difficulty of breathing after exertion also slowly left him; and he was dismissed greatly relieved, January 26th, 1852. Commentary.—Fatty liver was first shown by Mr. Bowman to depend ... _ ,*f^' on tne secretion of a large quantity of ■■'•' ft'A^'^ffil" *^W^^ft° °*1> winch is stored up in the hepatic .^yiSi^^^^/.-.H-j^^j^^^ cells. These cells are, under such cir Sp. ^Ether. NU. § ss; Pot. Acet. 3 ij ; Syr. Aurant. § j ; Aquee § ivss. M. A table-spoonful to be taken three times a day. July 1th.—Has now only three or four stools daily, which are faeculent. No dysuria. Urine more copious. Considerable uneasiness in the epigastric region. Omit. Mist. diuretica. Applicet. Emp. Lyttw (3 x 4) epigastrio. Habeat Enema Opiatum ves- pere. July 25th.—Since last report has had about three stools on an average daily. He feels much stronger. Aug. 1st.—Has had occasional exacerbations of fever, with thirst, accompanied by increased looseness, which have been checked by the Pil. Plumb. Opiat. From this date he continued slowly gaining strength, taking occa- sional exercise, but subject now and then to relapses, for which he was ordered tannin with opium, and occasional suppositories. Gradually the pus disappeared from the stools, which became more faeculen^ and regular. He was dismissed quite well, September 20th. Case LXXXV.f—Chronic Dysentery—Ascites and QjJdema of the Legs —Leucocythemia—Cirrhosis of the Liver—Cancer of the Lung. History.—Thomas Crease, aet. 28, single—admitted May 27th, 1857. Has been of intemperate habits. Since November 1856, has been troubled with violent cough —sputum being tinged with blood; voice hoarse; feet and legs more or less swollen, * Reported by Mr. J. D. Maclaren, Clinical Clerk. f Reported by Messrs. John Lowe and Stewart Lockie, Clinical Clerks. 528 DISEASES OF THE DIGESTIVE SYSTEM. hot and tender, especially around the ankles. This attack dated from a definite day which he could not name in November 1856, after exposure to cold while crossing at Queensferry. He was under treatment in the Infirmary from March 6th to April 28th, 1857; there were present during that time cough, with bloody or rusty sputum, which, however, occasionally became frothy and mucous; a doughy and ©edematous condition of the feet, and latterly of the hands; an unusual temperature of skin, and a pulse more or less thrilling and hard. There was no diarrhoea. After leaving hospital he was for four weeks under quack treatment; getting steaks, ale, and brandy almost ad libitum. No relief was obtained ; the heat of skin, thirst, and exhaustion continued, and the bowels became loose. The cough became less trouble- some, and the expectoration scanty. Symptoms on Admission.—Percussion note is rather flat on the right side of thorax anteriorly, and over the upper half on same side posteriorly. The respiratory murmurs are very feeble. When audible they are harsh; no sibilus nor moist rale; vocal resonance increased under right clavicle; no dyspnoea; no cough nor sputum to-day. Cardiac impulse weak; the transverse dulness is normal; the sounds are normal. The pulse 126, rather full and hard. The tongue is covered with fur; thirst great, appetite bad. Abdomen on palpitation is natural; no dulness on per- cussion, nor tenderness on pressure. The bowels are reported loose, but patient does not complain of their frequency. Urine is quite natural. The skin over the body generally is of an unusually high temperature and dry. No lesion of the nervous system; is exhausted, and is mentally despondent. Is ordered wine ( § iij) and saline diaphoretics. Progress of the Case.—May 31st.—Sputum rather frothy, semi-transparent gelatinous, slightly tinged with blood; pulse 114 ; febrile condition the same; the diarrhoea has not ceased. June 3d.—Diarrhoea continues; faeces of a light yellow color and pea-soup consistence, of an extremely faeculent odor, presenting on micro. scopic examination no blood discs nor other abnormal bodies. Ordered an astringent and chalk mixture. June 1th.—Febrile symptoms continue; ordered 3 grains of quu nine thrice daily. The diarrhoea slightly abated; continue the astringent mixture. June 11th.—Diarrhoea continues with much tenesmus; frequent calls (from 6 to 8 times) at night to stool; evacuations at each time are scanty; stools watery. let him have an opiate suppository at night, and after every stool let the following enema be administered:—R- Plumb. Acetat. 3j ; Aq. Distill. § iss; Sol. Mur. Morph. 3ss. June 15th.—Patient expresses himself as better, and the febrile excitement is dinu\ nished. June 24th.—The diarrhoea has not ceased; the injections cause pain, and are speedily ejected; they are now discontinued ; ordered half ounce of the decoction of the Indian Bael thrice daily. June 21th.—In addition to the decoction, let him have, thrice daily, one of the following powders:—R Ptdv. Cretce prep. 3 ij ; Confeci. Aromat. 3j; Pulv. opii gr. iij. M. et divide in chartulas duodecim. July 2d.—Febrile symptoms and diarrhoea much diminished; skin cooler; pulse 86, of moderate strength; oedema of the lesrs is much less than formerly. On the 4th, he becomes worse; en the 5th, feels better; on the 8th, diarrhoea again more severe, and febrile symptoms renewed. On the 9th, the blood was microscopically examined, and an increase of white cor- puscles was detected (from 20 to 25 being visible in one field), and the red discs ar- ranged themselves in irregular masses. On the 11th, the powders and decoction are discontinued, and a mixture of Kino, Catechu, and Simaruba was given. On the 13th, the diarrhoea being persistent, the use of the powders is resumed, and at night an astringent injection. On the 15th and llth, is better; on the 20th, is worse and seldom off the stool; on the 21st, is better, having had only three stools; on the 24th, has six stools, skin being burning hot, pulse 120, hard, and apparently strong, but patient complains of great debility. July 26th.—Great thirst; pain over abdo- men, which is relieved by a turpentine epithem. Abdomen is tense, with skin white, glistening, and dry; percussion very tympanitic anteriorly; is slightly dull over the flanks. July 28th.—Patient is extremely weak; faeces are passed in bed. Urine is examined and found non-albuminous; has been delirious this morning. July 29th.—No return of the delirium; swelling of abdomen increased; the diarrhoea and febrile state continue; pulse 112, very weak; great thirst. July 30ih.—Died this morning at 9.30 a.m. Sectio Cadaveris.—Forty-eight hours after death. Body.—Moderately emaciated; oedema of feet and legs; face with a peculiar fever- ish expression. Thorax.—Heart was quite natural. The two upper lobes of right lung healthy ; DISEASES OF THE INTESTINES. 529 the lower lobe felt heavy, presenting a rounded prominence about three inches in dia- meter projecting from its surface. On section it was found to be a mass of soft cancer, of an oval form, about the size of a fist; greyish or pinkish-white in color, with some opaque yellow patches (reticulum) intermixed with it. It readily broke down under pressure, and part had already undergone softening. In its neighbor- hood were two other masses of similar character, about the size of small marbles. In the lower lobe of the left lung there was a cancerous mass of the size of a filbert; otherwise the lung was healthy. The bronchial glands were natural. Abdomen.—The peritoneum contained nearly a gallon of a somewhat opalescent serum. The liver was of small size, and presented a coarsely granular surface. On section it was found in a moderately advanced state of cirrhosis; it weighed 2 lbs. 8 oz. The spleen was quite natural, and weighed 6 ounces. Kidneys healthy. Stomach normal. The coats of the small intestines were generally thickened and cedematous, but there was no trace of ulceration. The mucous membrane of the large intestines was found extensively ulcerated, chiefly in the transverse and descending colon. There were a few ulcerations in the cascum and upper part of the rectum; they ceased alto- gether about 3 inches above the anus. The calibre of the intestine was diminished. The ulcerations were of a very chronic character, there being no increased vascularity of the surrounding mucous membrane. They were generally arranged in a linear direction, parallel to the long axis of the gut. Many were nearly cicatrized, present- ing in the base and margin an accumulation of dark-colored pigment. There were pretty numerous slate-colored cicatrices, indicating the position of former ulcers. No other lesion was found. Microscopic Examination.—The cancerous exudation in the lungs contained numerous cancer cells in all stages of development. Some of them were very large, and contained from three to five secondary cells. Several of them contained clear collections of fluid, as represented Fig. 294. Commentary.—The three cases now related present the same disease in different degrees of severity. In the first, there is every reason to suppose that, though severe, it was not extensive. In the second, it was more chronic, but ultimately the patient got well. In the third, it went on to such extensive ulceration, kept up such constant irritative fever, and so interfered with nutrition, as, conjoined with the other lesions under which the man labored, to cause death; on dissection afterwards it was seen that he had had chronic disease of the liver, which had caused ascites and oedema of the extremities. On this had supervened the in- flammation of the lower bowel, especially of the colon, which had pro- ceeded to ulceration, extending over a considerable portion of the mucous membrane. In many places the ulcers had healed, while in others there was exhibited a tendency to cicatrization; and it is very possible that a recovery might have occurred in this case, as in the one which pre- ceded it, but for the hepatic disease, which, by keeping up constant congestion of the portal system, and therefore of the intestinal venous capillaries, must have opposed itself to all successful efforts at cure of the ulcers. The masses of cancer developed in the lower portion of the lungs, and which gave rise to many of the symptoms of pneumonia, especially cough and bloody expectoration, cannot be said to have had any influence in producing the fatal termination. In the case of Crease I employed, as an astringent, a decoction of the unripe fruit of the Indian Bael, commonly called the Bengal Quince. It is said to contain tannin, both free and in a combined state, an aromatic principle, mucilage, and a small amount of a bitter substance supposed to be sedative. The decoction must be used fresh, and is prepared by sim- mering two ounces of the unripe fruit in a pint of water down to a fourth, of which from one to three table-spoonfuls constitute a dose. In the case of a gentleman under my care, whose obstinate diarrhoea had 530 DISEASES OF THE DIGESTIVE SYSTEM. resisted all the usual means, this decoction checked the disorder perman- ently after a few doses; and I have since given it with great advantage in similar cases. In the case of Crease it was of no benefit whatever. Indeed it cannot be supposed that where actual ulcerations exist over a considerable portion of the mucous surface of the colon, any remedies can produce an impression on the alvine discharges. These are the result of the organic lesion, so that medicines merely directed to the symptoms, unless they favor cicatrization, cannot operate with effect. This requires time, general health of body, avoidance of irritating food and mental excitement, quietude, a good atmosphere, pure water, etc. etc.—in short, local agents must be combined with all those general remedies and hygienic conditions calculated to improve the vital powers, and favor regeneration of tissue. Diarrhoea and dysentery pass into one another; a great variety of lesions may induce the first, but the last is considered to be a true in- flammation of the large intestines. Hence the symptoms of dysentery are local pain, accompanied by fever, and attended with a discharge from the bowels, first of blood and then of pus. The blood results from rup- ture of the capillaries consequent upon their congestion, and is mingled with the mucous discharge. Fluid exudation is at first poured out on the surface and passes away from the bowels with the excess of mucus and blood, but subsequently purulent matter is thrown off from the ulcerated surface of the mucous membrane. The character of the faecal evacuations should be carefully attended to, not only in dysentery, but in all forms of intestinal disease. In health the faecal evacuation consists of a soft solid mass, forming a mould of the outlet at the anus. It is mingled with bile, and presents a dark brown color. Its odor, though faecal, is not putrid. As a general rule, the more the alvine evacuation departs from its normal consistence, color, and odor, the more violent is the cause which occasions the change. Thus, as regards consistence, the discharge from the bowels may be fluid, though faeculent, sometimes resembling pea-soup, the characteristic stools of active typhus. The discharge, again, may be watery through an excessive amount of serum, resulting from congestion of the vessels, or occasioned by saline and drastic cathartics. In cholera the discharge resembles rice-water, and is largely mingled with pure desquamated epithelium. It may consist of shreds of glairy mucus, which is very common in females with uterine disease, and sometimes of masses of recently coagulated exudation, or a substance like white of egg. In color it may be paler than natural, to such a degree as to be clay-colored or almost white, indicating a diminished quantity of bile. It may be red, reddish-brown, grass-green, or absolutely black, from the presence of blood, and according as blood has been poured into the in- testine more or less near its outlet, or as chemical changes have occurred in it before being discharged. In other cases it may be of a dark leaden hue, or of a dirty yellow more or less resembling pus. If pus and blood appear in the stools almost pure, then these fluids have been poured out not far from the orifice; the more they are mingled with faeculent or fluid matter the more is their origin distant. Constant fluid stools of a uniform color are generally derived from the small intestines. As to DISEASES OF THE INTESTINES. 531 odor, the more offensive and putrid, the greater is the indication of absence of bile in some cases, and prostration of the vital powers in others. In the examination of the feces the microscope will be found of the greatest service. (See p. 90.) The morbid anatomy of dysentery and of enteritis generally is a most extensive subject, for which I must refer you to the various special works which treat of it. It will suffice to say that the seat of the exudation is for the most part the areolar texture below the basement membrane, but pressing principally on the mucous surface, and giving rise to hemor- rhages, ulcerations, purulent discharges, etc. If the disease be chronic, the muscular coat becomes hypertrophied, causing thickening and rigidity of the intestinal tube. If violent gangrene occur, the mucous surface after death presents a deep red color, which is caused by congestion of the vessels; sometimes bright green patches are mingled with the red, and result from alteration in the color of extravasated blood; then again, brown or blackish sloughs may be observed from decomposition of the injured texture. Typhoid enteritis will be subsequently described (See Fever.) Tubercular enteritis is a common complication of phthisis, generally hurrying on the fatal result. Cancerous enteritis is by no means uncommon. The structural changes observed in the mucous membrane in cases of diarrhoea and dysentery are—1st, Degeneration of the epithelium; 2d, Congestion of the vessels and hemorrhage; 3d, Exudation; 4th, Mor- bid changes in the various glands; 5th, Waxy degeneration. 1. The readiness with which the epithelium is separated from the basement membrane of the intestinal mucous membrane varies much in different animals. For instance, I have found it to be easily separable in dogs, while in cats it is very firmly adherent. This circumstance ex- plains, to a certain extent, the different ideas put forth by experimental- ists as to the function of the epithelium in digestion. Some maintain that it is cast off so as to admit of endosmose through the naked villus; whilst others maintain that endosmose is carried on through the agency of the epithelial cells themselves in situ, which I believe to be the cor- rect doctrine. In man the epithelial cells are easily separated, and their separation consti- tutes a morbid state of great importance, be- cause if, as I suppose, they be the organs of primary assimilation, their removal must interfere with nutri- tion. This I consider Fig. 430. to be one of the reasons why chronic diarrhoeas, and more especially Fig. 430. Vascular congestion and sugillation of the mucous membrane of the small intestine in cholera, a and b, Congested tortuous vessels in villi, which are deprived of epithelium; c, The veins only congested in four villi; d, Extravasation of blood below the basement membrane, and around the glands of Lieberkuhn.—(Wedl.) 50 diam. 532 DISEASES OF THE DIGESTIVE SYSTEM. cholera, in which disorder the rice-water stools consist chiefly of serum, containing desquamated epithelium, are so prostrating to the economy. Of course the interference with nutrition so occasioned will be in propor- tion to the extent of mucous membrane affected. 2. Great congestion of the vascular plexus, which ramifies in the villi and around the glands, is one of the most common appearances seen after death in the intestinal mucous membrane; it is often associated with extravasations of blood more or less extensive. This lesion may be conjoined with all the others to which this texture is liable, and is at once visible both to the naked eye and on microscopic observation. In all cases of acute diarrhoea, dysentery, and in cholera, this morbid change may be recognised. 3. Exudation may occur below the basement membrane, infiltrating the areolar texture between it and the mucous coat, occupying the villi and surrounding the various glands; or, more rarely, it may appear on the surface of the mucous membrane, presenting adherent coagula. In the former case it undergoes the usual transformations, giving rise, according to circumstances, to purulent collections, fibrous growths, or ulcerations varying in extent, which may or may not ultimately cicatrizo. In the latter case the coagulated exudation rarely presents a fibrillated structure, but rather a dense ag- gregation of fibrinous amorphous substance, which disintegrates or passes into pus. With- in the villi it often assumes an opaque brown- ish color, and passes into granule cells, while the blood, which has been extravasated or ar- rested in the vessels, is transformed into black pigment. (Fig. 431, J, c, and d). 4. The morbid changes in the various glands have been more especially studied in relation to typhoid fever, under which head I shall again refer to them. There can be no doubt, however, that the glands of Brunner and Lieberkuhn, as well as those of Peyer, are constantly undergoing alterations, pro- bably similar to those so well described by Dr. Handheld Jones in the stomach, although few histological and clinical researches have as yet been made regarding them. In children, in whom the intestinal mucous membrane is active and easily irritated, the shut sacs of Peyer are often unusually large (Fig. 432.) 5. Waxy degeneration of the villi and mucous membrane, generally extending over a greater or less portion of the surface, may now be re- garded as a fruitful source of constant diarrhoea. This I have ascertained to exist in many cases of leucocythemia, with a similar degeneration in various organs, especially the spleen, liver, and kidneys. In such cases uncontrollable diarrhoea is a leading symptom. The thin translucent tissue under such circumstances appears to favor the transmission of Fig. 431. a, Granular mass, in recent exudation on the surface of the intestinal mucous membrane ; b, summit of a villus, containing black pigment, at -+•, in_a ves- sel ; c, Summit of a villus, containing a brown exudation; d, Another villus, with the exudation transformed into granule cells and masses.—(Wedl.) 250 diam. Fig. 431. DISEASES OF THE INTESTINES. 533 serous fluids through it, as we shall see is remarkably the case in certain forms of Bright's disease. The treatment of ordinary dysentery, such as we meet with in this country, may be gathered from the cases recorded. It consists—1st, In careful regulation of the diet, which should be nutritive but unirritating; 2d, In confinement to bed; 3d, In the use of antacids and astringents to check the discharges; and 4th, In the employment of leeches, fo- mentations, and poultices locally, and of opium internally to relieve pain and diminish irritability. It should not be forgotten, however, that, although in consequence of in- flammation there may be abundant diarrhoea, this may be conjoined with a true constipation; in other words, the excrement which it is necessary for the body to throw out, may be retained in the caecum or upper part of the canal, in consequence of the contraction or irritability of the canal lower down. Hence it is necessary occasionally to administer a small dose of castor-oil or other mild aperient, to secure the passage of effete matter from the system, a point in practice requiring great care and experience. Whenever dysentery is violent and epidemic, I have long been per- suaded that the former antiphlogistic treatment, followed by calomel, etc., was opposed to a sound pathology in this as in all other inflammations. I was, therefore, much gratified to observe* that Dr. W. L. Lindsay, physician to the Ballarat Hospital, has recently treated no less than 63 cases simply by means of rest and nutrients, with the result of invari- able success. Fig. 432. Derangements of the alimentary canal constitute the great majority of children's diseases. In them this portion of the economy is actively engaged, not only in developing itself, but in producing by means of digestion and assimilation, an excess of nutritive materials for the blood. During these processes of evolution, the functions of the alimentary canal are especially liable to be disordered, and frequently, as a result of the irritations thereby occasioned, various convulsive or diastaltic affections arise. In all such cases the practitioner should endeavor to remove local irritations and support nutrition. The former object is best accomplished by antacid medicines, especially chalk and magnesia, and occasionally a mild aperient, such as castor-oil; the latter, by careful attention to the diet, procuring a healthy nurse, etc. The con- stant flow of saliva during dentition, the vomitings from over distension * Australian Medical Observer, October 1864. Fig. 432. An enlarged Peyerian sac from the colon of a child, a, Glands of Lie- berkuhn ; b, Muscular layer; c, Sub-mucous tissue; d, Transverse muscles; e, Serous membrane; f, Depression of mucous membrane over the sac, g.—(Kolliker.) 50 diam. 534 DISEASES OF THE DIGESTIVE SYSTEM. of the stomach, and occasional diarrhoea in weak children, are often salutary discharges, which only require watching and hygienic regulation, and will, it is hoped, no longer be mistaken for symptoms of an active inflammation which requires antiphlogistic remedies Case LXXXVI.*—Obstruction of the larye Lntestine—Cancer of Stomach Liver, Peritoneum yenerally, and Mesenteric Glands. History.—James Sturgeon, aet. 21, tax-collector—admitted into the Clinical Ward of the Royal Infirmary, September 14, 1853. He noticed for the first time last Janu- ary that his appetite had diminished, and he was greatly troubled with flatulence vomiting, and constipation. These symptoms continued until three months ago, when the abdomen became swollen, and gradually so distended, that he applied to Dr. Alison, under whose treatment the vomiting nearly disappeared. He then noticed several hard lumps in the abdomen, varying in size from a walnut to a hen's egg. These since then, have continued to increase in size, and have become very painful on pressure. Progress of the Case.—October 26ih.—Since his admission the appetite has been gradually failing, and he has become daily thinner and weaker. He has experienced considerable pain in the abdomen, combined with a feeling of tightness and constric- tion there. It has always felt tense, and contained more or less fluid, but until a fortnight ago, the tumors formerly mentioned could be felt very distinctly, separated from the walls of the abdomen by a thin layer of fluid. The bowels have been greatly constipated. The treatment has consisted in the administration of diuretics of every kind, with strong purgatives, enemata, warm fomentations to the abdomen, and occasionally anodyne draughts at night. On taking charge of this patient to-day, I found his condition as follows :—Great emaciation; complexion of a cachectic waxy appearance; skin cold and dry; tongue moist, with a brownish fur; breath offensive; very little appetite; only occasional vomiting; and no thirst. Bowels have not been opened for four days, a draught of castor-oil with a drop of croton-oil having merely brought away a few hard lumps of faeces of a dark color. Purgatives do not cause griping. The abdomen is greatly enlarged, and tense, but with a distinct feeling of fluctuation. No tumors can now be felt, but during inspiration distinct friction can be felt by the hand, and heard by means of the stethoscope. Pressure causes a trifling obscure amount of pain, but his chief complaint is from the sense of constric- tion. The pulse is 10; regular and feeble. A murmur is audible with the first sound of the heart, at the base; action is regular; no palpitation. There is dry cough and slight dyspnoea. The respiratory sounds are feeble, but otherwise seem natural. Urine healthy. From this time he gradually sunk. GUdema appeared in the inferior ex- tremities ; vomiting became more severe, and at length constant, whenever food or drink was taken. AH kinds of medicines failed even as palliatives; emaciation became extreme, and he sank November 5, the bowels having been obstinately closed for ten days. Seclio Cadaveris.—Forty hours after death. Thorax.—Pulmonary tissue everywhere spongy and crepitant. On the superior lobe of the left lung there were two cicatrices, and on the right pulmonary pleura there were similar patches, more widely scattered, extending over the whole of superior, mid- dle, and inferior lobes. Purulent mucus was easily pressed from several of the bronchi. No carcinomatous nodules were found in the pulmonary tissue, but the whole intercos- tal pleura was studded over with small irregular plates of cancerous exudation, bearing a considerable resemblance to the eruption of small-pox. Heart small; muscular sub- stance pale fawn-colored. The pericardium shows on its external surface numerous cancerous nodules from the size of a pin's head to that of a small flattened coffee bean. Bronchial glands at the root of lung swollen, some of them the size of a pigeon's egg; all infiltrated with cancer, and some mingled with black pigment. Abdomen.—The liver was smooth on its surface. Inferiorly and laterally it was closely adherent to the diaphragm, the pleural surface of which was covered by lami- nae of cancerous matter. On stripping off the diaphragm the peritoneal covering of the liver was seen infiltrated with cancer, in some places to the depth of half an inch. Substance of liver presented the usual appearance of the white tubercle of Farre; it * Reported by Mr. Win. Calder, Clinical Clerk. DISEASES OF THE INTESTINES. 535 was pale, soft, and very fatty. The spigelian lobe of the liver, the omentum, epigastric glands, spleen, and pancreas, were united togettier, and formed a large irregular whitish mass extending across the abdomen, and weighing 4 lbs. This mass formed, on the right side, a dense wedge pressing in the right iliac fossa upon the ascending colon im- mediately as it leaves the caecum; this bowel was filled, but not distended, with firm yellow faeces, but the ascending, descending, and transverse colon were empty and collapsed. The peritoneum covering the intestine was dotted all over with nodular projecting masses, varying in size from a millet seed to a hazel nut, in color from white to deep red, and even almost black, and in consistence from soft pulpy matter to nodules considerably indurated. The whole of the abdominal peritoneum was closely covered with similar irregular nodules, for the most part of soft consistence, with here and there a little coagulated blood. There were two gallons of sanguineous serum in the peritoneal cavity. Spleen small but healthy; it was closely adherent to the dia- phragm above and the cancerous mass below, and on section seemed to be surrounded by a thin layer of cancer infiltrated in the peritoneum superiorly while inferiorly the cancerous mass all around it is 1-J- inch in thickness. Stomach imbedded, and also compressed, in the cancerous mass, which was everywhere adherent to its peritoneal surface. Its mucous membrane, as well as that of the alimentary canal, was quite healthy. On section of the mass it presented the uniform appearance of white lard, giving to the finger a feeling of considerable firmness. It yielded no canberous juice, but was friable, readily breaking down under pressure. Microscopic Examination.—The whole of the cancerous exudation on the peri- toneum exhibited numerous cancer cells, in some places mingled with fibres, in others associated with numerous oil granules and granular cells. The white masses on the pleurae were principally composed of fibres, but on the addition of acetic acid might be seen to be crowded with cancer nuclei. Commentary.—In this case it was observable that the vomiting did not occur regularly after taking food, and that the ejected matters con- sisted of the ingesta, and were never mixed with recently extravasated or altered blood. This indicated that no ulcer or erosion of the stomach had taken place. That the peritoneum and mesenteric glands were the principal textures involved, was indicated by the nodular swellings felt, and the friction sound audible over the peritoneum, and the abdominal distension from accumulation of fluid. The continued constipation also indicated some mechanical contraction of the gut, obviously owing to cancerous deposition in some way pressing on or constricting it,—all which suppositions were proved to be correct ou examination of the body after death. Case LXXXVIL*—Strangulation of the Small Intestine from Inguinal Hernia—Gangrene, Ulceration, and Perforation of the Intestine— Peritonitis. History.—Margaret Bruce, aet. 41—admitted September 25th, 1848. Says that she has occasionally had a swelling in the left groin for the last nine years, that has always gone away on lying down and applying warm fomentations. On the 18th, while car- rying a large bucket of water up stairs, she felt something give way in the left groin. On the following morning she suddenly awoke with rigors, shortly followed by nausea and vomiting. The left groin also felt painful, and she perceived a tumor there th 3 size of a man's fist. Purgatives were now taken without causing any action of th.: bowels. The vomiting, however, became more intense, and the matter ejected mc; j of a dark-brown color. In this condition she has continued ever since. Symptoms on Admission.—On admission she lay on her back, with the thighs flexed on the abdomen. The countenance was sharp, sallow, and expressive of great suffering. Extremities cold. Pulse 120, small and weak. Respiration difficult, especially during inspiration. Percussion and auscultation of the chest elicit nothing abnormal. Tongue white, but red at the top and edges. Bowels have not been opened for eight days, and * Reported by Mr. T. N. Fanning, Clinical Clerk. 536 DISEASES OF THE DIGESTIVE SYSTEM. there is frequent vomiting of matter like coffee. Skin of abdomen is hot and dis- tended, and she complains of great pain in the umbilical and left iliac regions on the slightest touch. A fluctuating tumor, the size of an orange, occupies the left groin, over Poupart's ligament. Urine scanty but normal. Menstruation has been irregular. Other functions normal. Mr. Syme was consulted, who opened the tumor, from which there was evacuated about 3 v of foetid serum, mixed with dirty yellow purulent mat- ter. Warm fomentations to be applied to the abdomen. To have one grain of opium in the form of pill immediately. In the evening the symptoms were the same, with the exception of the abdominal pain, which was more violent, and appeared as if she was cut with a sharp instrument. Has had three injections of warm water, which return unaltered. To have Pulv. Opii gr. ij. every hour. Progress of the Case.—September 26th.—No change. The opium produces no effect whatever. Strong beef tea to be taken in small quantities. To eat as much ice as she pleases. September 21th.—Vomiting, abdominal pain, and intestinal obstruction continue. Abdomen considerably swollen. Sore in the left groin looks very unhealthy. Thirst and dryness of the lips and fauces are much relieved by the pieces of solid ice. Has taken opium in three-grain doses every second or third hour, which has caused ap- parently no effect whatever. September 29th.—Vomited matters to-day are distinctly faeculent. The abdomen above the umbilicus and in left flank is greatly swollen, very tender, and tympanitic; over the right lower third it is collapsed. A dirty sanious discharge is poured from the wound in left groin. Pulse 110, very small and weak. Tongue brown and dry. Quite sensible, but much exhausted. Utters low moans, and complains principally of dryness of mouth and throat, which continues to be relieved by the ice. Bowels continue closed. To have a table-spoonful of wine and beef-tea every hour, and § viij of beef lea injected into the bowels slowly, night and morning. Pulv. Opii gr. iij, to be given only at night. September 30th.—The discharge from the groin to-day is fasculent, as well as the vomited matters. Complains of no pain, but there is commencing delirium. Pulse 100, scarcely to be felt. Prostration extreme. Distension of abdomen, and other symptoms the same. Died October 1st. Sectio Cadaver is.—Thirty-six houns after death. Body pale and emaciated. Over Poupart's ligament was an oval ulcer, measuring an inch and a half in it3 longest diameter, which was slightly oblique from above down- wards. Its base was superficial, of a brownish black color, and faeculent odor. Thorax.—Slight chronic adhesions between pleurae on right side. Lungs somewhat emphysematous anteriorly. Thoracic organs otherwise healthy. Abdomen.—On opening the abdominal cavity, the liver, stomach, and intestines superiorly, were seen to be covered by a uniform membranous expansion of lymph. The remainder of the intestines and the uterus were matted together, and bound down to the left side of the pelvis, leaving a considerable cavity in the right side, which was occupied by about a pint of dirty reddish-brown fluid, possessing a strong faeculent odor. On separating the intestines, a knuckle of the ileum, in its upper third, was found to be strangulated in the left inguinal ring presenting externally to it, and form- ing the base of the ulcer, two soft prominent projections. On the summits of these were two ragged ulcers perforating the gut. Into the superior of these a probe only passed a few lines; into the inferior it readily passed into the dilated and upper por- tion of the intestine. The duodenum, jejunum, and three or four feet of the ileum, up to the point of strangulation, were greatly distended with flatus and fluid faeces, resem bling that found in the right side of the peritoneal cavity. The small and large intes- tines below the strangulation were collapsed and apparently contracted. About eight inches from the strangulation, in the upper part of the gut, was an ulcer the size of a halfpenny, with two perforations in its centre, each about the size of a goose's quill, through which fluid faeces had escaped into the peritoneal cavity. For about eighteen inches, extending from the strangulation, the ileum was of a dark mahogany, and in the centre, as well as near the strangulation, of a claret color, evidently gangrenous. The rest of the intestines and other abdominal organs were healthy in texture. The gall-bladder was distended with tenacious bile, having the appearance of tar. Commentary.—In this case the intestine had been strangulated in the inguinal ring seven days previous to admission, and the symptoms on her coming into the house were not only those of intestinal obstruction, DISEASES OF THE INTESTINES. 53V but of peritonitis also. Purgatives had been administered before she came in. Mr. Syme recognised an abscess, which was opened without causing relief, external to, and covering the hernia. In the evening, peritonitis, with symptoms of perforation, were more unequivocally pro- nounced, and the case became hopeless. Large doses of opium failed to relieve the pain. Ileus was established on the 11th, and an artificial anus on the 13th day, without relief—gangrene and perforation of the intestine having caused escape of faeces into the peritoneum, and of course death. The two cases previously given exemplify two modes in which the intestinal canal may become permanently obstructed—viz., by morbid growths compressing it from without, and by the strangulation of a her- nial protrusion. An instance of internal obstruction from a band of lymph acting as a ligature, and constricting the gut, will be found un- der the head of Ovarian Dropsy. (Case of Jessie Fleming.) A variety of other causes may also occasion permanent obstruction, such as invagi- nation, accumulation of faeces or foreign bodies, and calculi impacted in the tube, inflammation, gangrene, paralysis, etc. In most of these cases distension of the upper and corresponding collapse of the inferior portion of the intestine occur, followed at length by ulceration or rupture, occa- sioning fatal peritonitis. Vomiting is a common symptom of permanent obstruction, and when the disease is far advanced, the faeces are propelled backwards, and rendered by the mouth, constituting ileus, as in Case LXXXVII. The pathology of this anti-persistaltic action of the tube has been much discussed, more especially as to whether it be owing primarily to spasmodic contraction, or to paralysis. In all such cases it has been found that one portion of the intestine has been over-distended, and another collapsed, and this even though a mechanical obstruction does not exist. A portion of the tube may be inflamed, and even gangrenous, giving rise to ileus, without the passage being actually closed.* In these cases the cause of the obstruction producing ileus is not easy to deter- mine ; but the reasoning of Abercrombie on this point has always ap- peared to me so good, that I shall quote it in his own words. " If we suppose, then, that a considerable tract of the canal is in a collapsed state, and that a mass of alimentary matter is propelled into it by the contrac- tion of the parts above, the series of actions which will take place will probably be the following:—When a portion, which we shall call No. 1, is propelling its contents into a portion No. 2, the force exerted must be such as both to propel these contents, and also to overcome the tonic contraction of No. 2. The portion No. 2 then contracts in its turn, and propels the matter into No. 3; this into No. 4, and so on. Now, for this process going on in a healthy manner, it is necessary that each por- tion shall act in consecutive harmony with the other portions ; but there appear to be several ways in which we may suppose this harmony to be interrupted; (1st), If the portion No. 1 has contracted and propelled its contents into No. 2, and No. 2 does not contract in its turn, the function * See Abercrombie on Diseases of the Stomach and Abdominal Viscera.—Cases xxx. xxxi. and xxxvii. 538 DISEASES OF THE DIGESTIVE SYSTEM. of the whole will be to a certain extent interrupted, and the contents will lodge in No. 2 as in an inanimate sac. The parts above continuing to act downwards, one of two results will now take place; either the parts above will be excited to increased contraction, and the matters will' be forced through into No. 3, independently of the action of No. 2, and so the action be continued; or, new matter being propelled into No. 2 this will be more and more distended, until an interruption of a very formi- dable nature takes place in the function of the canal. (2), If, in the series of actions now referred to, No. 2 contracts in its turn, while some obstacles exists to the free dilatation of No. 3, it is probable the motion may be so inverted, that the contraction of No. 2 may dilate No. 1, and that the action may thus be communicated backwards. In the state of parts here referred to, varieties may occur, which appear to give rise to important differences in the phenomena. The obstruction to the dilata- tion of No. 3 may exist in various degrees ; in a smaller degree, it may not prevent it from acting in harmony with other parts, when the quan- ' tity of contents is small, and only a small degree of dilatation is re- quired ; but, when there is an increased distension of the parts above, either from increase of solid contents or from some accidental accumula- tion of flatus, then a greater degree of expansion may be required than No. 3 is capable of, and in this manner interruption may take place to the harmonious action of the canal. It is probably in this manner that, in connection with slight organic affections of the canal, we find the patient liable to attacks of pain and other concomitant symptoms, which at first occur only at long and uncertain intervals, but at length termi- nate in fatal ileus." In the summer of 1853, a valuable lesson was presented to us in the case of a man, John Johnstone, who had long been subject to inguinal hernia, and in whom, as the result of strangulation, violent vomiting and abdominal pain had existed for three days previous to admission. On the third day, he went to a medical man, who sent him into the medical ward, not having discovered the hernia. This Was simply the result of non-examination (see p. 28, Rule 4), and strongly inculcates the duty of carefully feeling and investigating into the disease, rather than hurriedly acting upon the prominent symptoms referred to by the patient. It so happened that the hernia disappeared three hours after admission spontaneously, before I saw the man, who from that moment , recovered. The treatment of intestinal obstruction, however it originates, must always be a matter of anxious consideration. At first, it is more or less difficult to determine whether there be only an obstinate constipation. which may be overcome by purgatives, or whether there be a mechanical obstruction, rendering them useless and perhaps dangerous. Under these circumstances, I think one full purgative at least should always be given as a rule, for the simple reason, that npt only may its action overcome many forms of simple obstruction, but because without it no one can determine whether or not there is an obstruction at all. As soon, however, as it becomes evident with what we have to do, all attempts to stimulate the action of the canal from above should cease, and we must have recourse to anodynes to diminish spasm, lessen irritability, and, INTESTINAL WORMS. 539 if possible, cause relaxation. Surgical means may be had recourse to, if the nature of the case admit of them, and operations performed with a view of relieving the strangulation or extracting any impacted mass; and the colon may be dilated with oil, air, or other fluid, by means of long tubes. These important points, however, are so purely surgical, that I need not dwell upon them here. INTESTINAL WORMS. The observations of recent helminthologists, but more especially of Siebold, Van Beneden, Dujardin, Leuckart, Steenstrup, and Blanchard, have cleared away the mystery which so long hung over the origin of tape-worms and other entozoa. It seems now determined that tape- worms are only further stages of development of Cysticerci, as flukes are only further stages in growth of certain Cercarise. This important fact is a result of the researches now everywhere prosecuted with so much zeal by anatomists and physiologists in embryology, and from which it has resulted that many animals hitherto considered altogether distinct species, bear the same relation to each other as a caterpillar does to a butterfly. Professor Siebold first pointed out that the Cysticercus fasciolaris found in the liver of the mouse, reaches its ultimate stage of develop- ment in the intestines of the cat, and is there transformed into the Taenia crassicollis. This fact was confirmed by a careful series of observations made by Dr. Henry Nelson, who, in his Thesis presented to this University in 1850, carefully traced and figured all the various stages which the tape-worm of the cat passes through. Each joint of this worm is estimated to contain 125,000 ova, which gives for the entire animal about 12,500,000. These minute bodies pass off by the faeces in incalculable numbers, and enter the body of the mouse mixed with its food or drink, or by licking its furry coat, to which they adhere. From the alimentary canal of the mouse they may enter the liver of that animal in three ways : 1st, They may ascend the bile-ducts. 2dly, They may pass through the coats of the intestine, and penetrate the adjoining portion of the liver. 3dly, They may bore their way into one of the mesenteric veins, and be carried by the blood along the vena porta to the liver. Dr. Nelson considers the last to be the most correct view, for, as he shows, the ova are furnished with temporary teeth, which en- able them to pierce the tissues. That they do not perforate the intestine, and so get into the liver, is shown by the fact that they are most devel- oped on the surface of that organ, and least so in its interior. Neither are they found especially in the biliary ducts, like the Distomata. Hence the blood-vessels seem to be the channel of their introduction— an idea still further supported by facts, the number of which is rapidly augmenting, which demonstrate the presence of entozoa in various stages of development in the blood itself. Arrived at the liver, these ova are transformed into Cysticerci fasciolares, and would never proceed further in development in the mouse; but being eaten by the cat, they become tape-worms, and are developed into Toznxce crassicolles. 540 DISEASES OF THE DIGESTIVE SYSTEM. This series of observations renders it probable that all the various kinds of Taenia are only different Cysticerci in advanced stages of devel- opment. Dr. Nelson points out that " the head of the Cysticercus cellu- losus resembles in every respect that of the Taenia solium of man. The two figures given by Bremser are identical, if we allow for stretching of the neck in the latter. Both have a double circle of hooks, and al though the Taenia solium is sometimes found without any teeth, Bremser has fully proved that this is the result of age, and not the original con- dition. He also observed that as the worm increased in age, one row of the double corona first fell off, and was after a time followed by the other, leaving the worm thus unarmed. The size of the head in both is similar, as also are the attenuated neck and the gradually increasing body." Besides, man feeds on animals in which these Cysticerci are common, especially on the pig and sheep ; and it has been observed that, in countries where meat is often eaten raw, as in Abyssinia, tape-worms are very common. The reason of the rare occurrence of Taenia in civi- lised countries, is probably owing to the cooking of food, which destroys the vitality of the Cysticerci. Very thorough curing or salting meat also appears to produce the same effect. However, it may easily be con- ceived, that owing to meat being very underdone, or to the tenacity of life in certain of these creatures (and many of them resist a high tem- perature without injury), they may occasionally escape the action of the teeth, arrive living in the human stomach, and be converted into young Taeniae. These ideas with regard to the origin of tape-worms have been con- verted into certainties by the experiments of Dr. Kuchenmeister, first recorded in the Prague Vierteljahrschrift (Band i. 1852, p. 126). He fed dogs and cats upon parts of animals which contained different kinds of Cysticerci, and subsequently found the tape-worms into which these had been transformed in various stages of development, according as the life of the animal who had eaten the Cysticerci had been more or less prolonged afterwards. Every precaution seems to have been used in these experiments, one of which may be cited :—An old dog, during a period of from six to eight weeks, was frequently purged with castor-oil, so as to prevent the possibility of tape-worms being present. On the 18th of March, 1851, he ate food containing ten Cysticerci; on the 25th he ate as many more; and on the 1st of April, several others which were not numbered. On the 10th of April, the dog was killed, and thirty-five Taeniae were found in the intestines, of which five were from 124 to 390 millimetres (from about 5 to 15 inches) in length, and possess- ed from 130 to 160 joints. There were six others, from 25 to 96 mil- limetres (1 to 5 inches) in length, having from 40 to 60 joints. There were 21 others, which measured from 8 to 16 millimetres (£ to £ an inch) in length, in which the joints were so indistinct that they could not be counted. Lastly, there were three, measuring from 4 to 5 milli- metres (^th of an inch) in length, in which the joints could scarcely be distinguished. Considering the power of construction and elongation possessed by these worms, their length was not so decided a character of their stage of development, as the size of the head and hooks, which corresponded to the three periods in which the Cysticerci had been INTESTINAL WORMS. 541 swallowed. Similar results have since been obtained in cats; and even in a man—a condemned criminal—to whom Kuchenmeister gave Cys- ticerci in broth, and found tape-worms in his intestinal canal after death. On feeding dogs upon the liver of a mouse, containing the C. fasciolaris, Dr. Kuchenmeister never found Taeniae in the intestines. But when he fed cats on the same liver, the intestines contained the Tania crassicollis. This observation indicates that not only are certain Cysticerci transformed into certain Taeniae, but the former can only undergo this transformation in certain habitats, or in peculiar animals. Although the present amount of our knowledge does not enable us to state from what kinds of Cysticerci many species of Taeniae are formed, it seems probable from the observations of Siebold, Nelson, and Kuchenmeister, that the Cysticercus fasciolaris of the mouse is trans- formed into the Taenia crassicollis of the cat; the C. pisiformis of hares and rabbits into the T. crassiceps of the fox; the C. tenuicollis of rumi- nantia and squirrels into the T. serrata, so common in the dog; and the C. cellxdosus of the pig, sheep, and rabbit, into the Taenia solium of man. It is also tolerably certain, from the observations of Eschricht, that the Bothriocephalic latus found in man in certain countries, especially in Russia, is the further development of a species of Ligula, which exists in large numbers in the flesh of the dorse, and other fish of the northern seas. Numerous instances have occurred, especially in India, where men encamped on the borders of a lake have subsequently been attaeked by tape-worm, evidently in consequence of the water they consumed con- taining the ova of the worm. The parasite also has been known to infect Hindoos who have eaten no flesh. There can be little doubt, therefore, that the numerous ova of tape-worms voided by animals may enter the intestines of man with the food or drink, and there be transformed into Taeniae. This direct mode of entry must not be overlooked while inves- tigating the undoubted origin of the worm from its cystic stage of trans- formation in the tissues of other animals. Dr. Fleming considers that the frequency of measly pork in Ireland is due to the pig being reared in the peasant's cabin, where it has commonly a dog for its companion, which animal is almost always infected with tape-worm, and must void a multitude of minute ova that find ready access to the aliment of the other. " Experiment shows," he says " that the ' measle' is generated in the muscle of the pig by feeding it with ripe joints of the dog's tape-worm (the Tamia serrata, now considered to be the same as the Taenia solium or human tape-worm), and that the same tape-worm is developed in the intestines of a dog fed with fresh measly pork. The measle is not gene- rated in the dog by feeding it with the tape-worm eggs."* Why in some animals these ova are fully developed into Taeniae in the intestines, whilst in others they enter the blood and are transformed only into Cystic worms in the liver, brain, or other organs, is probably owing to peculi- arities of structure which have not yet been investigated. The importance of the head of tape-worms, so long recognised by practical physicians as the only certain proof of the complete expulsion of the worm, has also received an explanation from the researches of * Dublin Quarterly Journal of Med. Science, Feb. 1851. 542 DISEASES OF THE DIGESTIVE SYSTEM. helminthologists into the anatomy and development of these animala Notwithstanding the doubts expressed by Van Benedin as to the lateral canals being connected with the digestive system, and his notion of their being peculiar secreting organs, Dr. Nelson in his Thesis has distinctly traced them into the suckers of the Taenia crassicollis. From each of the four suckers canals descend, which afterwards unite, two and two to form the lateral canals. He also carefully describes the manner of feed- ing and propulsion of the contents of these canals from the cephalic to the caudal segment. Hence the head is important as the means by which the animal is nourished. But the head is further important, as pointed out by Van Benedin, as the part from which all the joints are thrown off by gemmiferous re- production—those formed first being pushed downwards, and afterwards undergoing further development. Hence why the joints are narrow near the head, and become larger and longer near the tail. These caudal joints after a time separate, and then, according to Van Benedin, may still go on developing, and become, he thinks, a species of fluke or distoma. In fact, he considers a tape-worm as a compound fluke-worm, the whole consisting of three stages or periods:—1, The cystic head (Scolex); 2, The compound tape-worm (Strobild); 3, The separate joint (Proglottis). This latter view, however, is opposed by the observations of Steenstrup as to the development of the fluke, as well as by what we know of the arrangement of the nervous and digestive systems of this entozoon. The intestinal worms hitherto discovered in man are—the Ascaru lumbricoides ; Tamia solium ; Bothriocephalic lotus ; Tricocephalus dispar; and Ascaris vermicularis. None of these are very common in Edin- burgh, a circumstance which I attribute to the diet of the people, as well as to the excellent quality of the water distributed over the town. In unhealthy children, indeed, Ascarides are occasionally observed, but such children seldom enter the Infirmary. Lumbricoid worms in man are very rarely observed here, whereas in certain districts on the Continent, and especially in the Rhenish provinces, the great majority of bodies I have seen examined contained them in abundance. Tape-worm also is very rare, though sometimes met with, of which the following cases are examples:— Case LXXXVIII.*—Tape-worm treated by the Ethereal Extract of the Male Shield Fern. History.—James Seth, aet 35, a weaver—admitted April 1th, 1852. When a boy he used to pass the lumbricoid worms; during the past six months he has also observed ascarides. It is now three years since he first noticed fragments of the tape-worm in his stools. These fragments were then about a foot in length, and were noticed at intervals of months. About twelve months ago the fragments oc- curred almost every day for six weeks, varying from single joints to a piece six feet in length. No long piece has been passed for three months. No information can be obtained as to the kind of food on which he has lived ; but his appetite has remained natural. Before admission he was treated with turpentine by the mouth, and also by injection. Progress of the Case.—April 8th.—To have 25 grains of the ethereal extract of the male shield fern; and in a few hours, a powder containing three grains of calomel, * Reported by Mr. William Broadbent, Clinical Clerk. INTESTINAL WORMS. 543 and one drachm of compound jalap powder. A pril 9th.—Several fragments of Taenia, in single or double joints, or in longer pieces, were passed, _ being 70 inches in all. They varied in breaacn from one-eignth to one-fourth of an inch. April 22d.—The dose was repeated on the 10th, but ouly two or three single joints were found. No further trace of the worm has been obtained by administration of castor-oil, and the patient was discharged cured. Wa3 re-admitted July 1st.—States that two months after he left the hospital he ag iin detected joints of the entozoon in his stools. He was at once ordered twenty- four grains of the ethereal extract of the male shield fern, and a subsequent dose of castor-oil. Numerous fragments, in all 8 feet in length, were discharged in the next stool. Jidy 9th.—The remedy was repeated on the 5th without further effect. Castor- oil has also been administered, but no fragments appear. Patient now states that he has been in the habit of drinking marsh water of impure quality, and of eating salt pork meat. July 13th. Dismissed cured. Case LXXXIX.*—Tape-worm expelled by the Ethereal Extract of the Male Shield Fern. History.—Catherine Watt, aet. 25, married, with children—admitted November 20th, 1854. She had always enjoyed good health, until three years ago, when joints of tape-worm passed from her involuntarily when out working, and they have con- tinued to pass from her involuntarily, and sometimes in large quantities by stool ever since. On one occasion she passed blood at stool with portions of tape-worm. Has taken various kinds of medicine, but, with the exception of turpentine, does not know what they were. They have all been ineffectual. Symptoms on Ahmission.—On admission, she complained of tenderness in the left iliac region, and of tenesmus when at stool; but, with the further exception of the frequent passage of joints of tape-worm, the functions of the body were performed with regularity. She was ordered 3 ij of the ethereal extract of the male shield fern, to be followed in the morning by § j of castor-oil. This caused the evacuation of seven joints of the worm, each of which was longer than they were broad. Another 3j dose of the extract was ordered at night, also to be followed by % j of castor-oil in the morning. Progress of the Case.— November 22d.—Only three joints of the worm passed. To have this evening 3 ss of the extract. Nov. 23d.—This morning after taking the oz. dose of castor-oil, she passed many separate joints, and several long portions of taenia. The whole together, when measured, was calculated to be about fifteen yards long. One portion was evidently formed of the joints of the worm near the head, as they were broader than they were long, and not above the tenth of an inch in length. Some joints were square, and others longer than they were broad, measuring from half an inch to three quarters of an inch in length. No head could be discovered, though carefully searched after. She remained in the house till the 6th of December; but although she took 3 ss of the extract three times, and one dose of 3ij, no more joints of the worm came away. This woman was freed from the worm for many months, but it subsequently returned. Case XC.f—Tape-worm expelled by the same remedy. History.—William Perry, aet. 6. son of a soldier—admitted November 19th, 1855. Has been troubled with the tape-worm since he was two years old. Has passed several joints often without medicine; doses of rhubarb and jalap have brought away more; the child has also taken turpentine. A year and a half ago he obtained a prescription at this Infirmary for a medicine which expelled a very large portion of the tape-worm. In six months it was necessary to repeat the same medicine, again with success. But the symptoms have again returned; the child is always hungry and wants drink ; complains of pain in his belly, and passes joints of the entozoon per rectum. His food latterly has been plain, consisting of milk, bread, tea, potatoes, and some meat. The meat is boiled for broth, and is shared with him by father and mother, neither of them being affected. He is fond of sugar, butter, and salt. * Reported by Mr. Almeric W. Seymour, Clinical Clerk. , f Reported by Mr. John Glen, Clinical Clerk. 544 DISEASES OF THE DIGESTIVE SYSTEM. Progress of the Case.—November 21st.—Ordered 30 grains of ethereal extract of the male shield fern, with a subsequent dose of castor-oil. Nov. 23d.__As the remedy was inefi'ectual, it was increased yesterday evening to one drachm. This morning, an unbroken mass consisting of six yards and six inches of the tape-worm joints was evacuated ; the smallest joints were one-fourth to one-sixth of an inch in breadth and length; the head was not found. Dec. 25th.—After other two adminis- trations of the extract, and more frequent administrations of castor-oil, no further fragments of the taenia have been procured ; was discharged. Commentary.—Of all the vermifuge remedies proposed for the ex- pulsion of tape-worm, I have found the ethereal extract of the male shield fern the most effectual—a preparation proposed by Peschier of Geneva, and since strongly recommended by Dr. Christison. That it readily dislodges large masses of the parasite, has been witnessed by all who have tried it, although it has not succeeded in every instance in permanently destroying or removing the animal. This, however, appears to me in great part, if not wholly, accounted for by the circumstance that patients, on being dismissed, return to the kind of food from which they originally received the ova of these worms. This is very likely to be the case in certain English counties, where bacon and other pre- parations of pork are common articles of diet among the people. Dr. Paterson, formerly of Tiverton, has recorded some very obstinate cases, which resisted the action of the male shield fern, of the kousso, and of turpentine.* Now, in Devon, pork is a very common article of diet, whilst in Scotland certainly it is not much employed as food. I carefully interrogated the woman, Catherine Watt, as to whether she had eaten pork, and she admitted, that about the time the disease commenced, her husband being out of work, her diet had been very poor, and had consisted in some measure of salt pork, and occasionally of rabbits. Whether the Cysticercus cellulosce, commonly found in the flesh of pigs, could have retained its vitality in the salt pork eaten by this woman cannot, of course, be stated with certainty. But it is worthy of remark, that the flesh of pork is frequently sold cheap to the lower orders, after it has been laid in brine for a very short period, or been imperfectly cured, so that the tenacious vitality of these Cysticerci, or of the ova of Taeniae, is by no means necessarily destroyed. Then, rabbits are known to be very commonly infested with Cysticerci; so that her indulgence in either kind of animal food may have been the means of introducing Taeniae into her economy. The general considerations previously given as to the origin and mode of development of tape-worms must render it evident that, whilst by means of vermifuge remedies the practitioner endeavors to expel such as are already formed, his chief reliance, in preventing their return, must be placed on careful attention to the food and drink consumed by his patient. XCI.f—Tape-Worm expelled by Kamala—Return of the Parasite—Ulti- mate Cure by Means of the Male Shield Fern. History.—Mary Park, set. 9, a thin, cachectic-looking girl, native of Edinburgh, where she has for the most part resided—admitted 11th January, 1859. Her mother * Monthly Journal of Medical Science, July 1854. f Reported by Mr. .H. Graham Dignum, Clinical Clerk. PERITONITIS. 545 states that for four years she has never been free from worms, for which she has taken turpentine, castor-oil, and other remedies, without benefit. Progress of the Case.—On the 12th of January a table-spoonful of castor-oil brought away a few long joints of a tape-worm. On the afternoon of the 16th of January two drachms of kamala in powder were given. On the same evening she had three motions followed early the next morning by a fourth. In the three first stools were several isolated joints of tape-worm, but in the fourth there was a mass, con- sisting of the body of the worm several yards long. A careful search was made for the head, but without success. The smallest joints were the tenth of an inch broad. Jan. 23d.—One drachm of kamala in powder was administered, followed by three copious motions, in which no portions of worm could be found. No more of the worm having passed, she was dismissed January 31st. This girl was re-admitted on the 24th of March, the mother saying that the tape- worm had returned. Another dose of kamala was given, and violent purging pro- duced, but no worms, and she was dismissed on the 9th of April. She was again admitted on the 25th of April, the mother bringing some joints of the tape-worm with her which the girl had passed. On April 21th, 3 ss of the extract of the male shield fern was given, which was followed at night by § ss of castor-oil. On the following morning a large mass of Taenia was expelled, about ten yards long; no head could be detected.—May 20th.—Another dose, with castor-oil, of the male shield fern was given, but no worm having passed, she was dismissed May 25th. I was informed by her mother two years afterwards that there had been no return of the parasite. Commentary.—Kamala has been recommended to us by medical men in India as a cheap and powerful anthelmintic, and has been pretty ex- tensively tried in this country. Dr. M'Kinnon, of the Horse Artillery, pnblished a brief account of it in the Indian Annals of Medical Science for October 1853; and it is referred to by Dr. Boyle in his Materia Medica as an active vermifuge. It is a dark brick-red colored powder, brushed off from the capsules of the Rottlera tinctoria, a species of euphorbiaciae found in the hilly portions of India. Under the micro- scope it exhibits a mass of blood-red semi-transparent granules more or less shrivelled, mingled with stellate hairs, to the irritating properties of which some have ascribed the vermicidal properties of the drug. The dose is from 3 ij to 3 iij for an adult. Dr. T. Anderson says an alcoholic tincture in § ss doses is also very effectual (Indian Annals, October 1855). Unlike the root of the male shield fern, it is in itself a violent purgative. I have now tried it in several cases, of which the above is one, and found that it failed in all, so that it became necessary to have recourse to the male shield fern. (See also Dr. Fleming on the Oil of the Male Shield Fern, in the Brit. Med. Journ. for January 16, 1864.) PERITONITIS. Case XCIL*—Acute Peritonitis—Recovery. History.—James Stephenson, set. 19, sailmaker—admitted March 21st, 1860. Patient states that he was well up to the 14th March, when he felt slight pain in the lower part of his abdomen. This increased in intensity, and spread over the whole of his abdomen, and on Saturday the 17th, feeling himself very ill, and having shiver- ings, with a feeling of coldness down his back, he consulted a medical man, who ordered him six pills, one of which was to be taken every six hours. He was purged once on the morning of the 18th, but getting worse he was ordered by the medical practitioner other pills, one to be taken every four hours, and three leeches to be applied to the abdomen. Although he says that he felt immediate relief on the applica- tion of the leeches, the pain continued to increase, up to the date of his admission. * Reported by Mr. Colville Browne, Clinical Clerk. 35 546 DISEASES OF THE DIGESTIVE SYSTEM. His appetite also completely went away; his thirst became excessive; he vomited everything taken; and has not had one stool since the 18th. Symptoms on Admission.—Tongue moist; a littlo streaked. Bowels constipated. There is great tenderness on pressure over the whole of the abdomen, especially in the hypogastric region, and it is somewhat tumid. Appetite very bad; vomits all kinds of food. Pulse 108, small, weak, and communicating a double thrill to the finger. Cardiac sounds normal. Has a slight cough, which causes him great agony in con sequence of the abdominal pain. Skin dry and hot. Has not slept, he says, since the commencement of his illness. Urine of an amber color. Natural in quantity, sp. gr. 1030. No albumen present. Chlorides absent. Habeat opii granum unum quague sexta hora. Warm fomentations to be sedulously applied to the abdomen. Progress of the Case.—March 22d.—Bowels still unmoved; abdomen not quite so tender on pressure; tongue same as at last report. Vomiting has continued since admittance, and is now accompanied by occasional hiccough. Last night his pulse being very weak, he was ordered 4 oz. of brandy. To have a pint of olive oil, thrown gradually up the lower bowel as an enema. Vespere, the enema was given, but the oil came away without any faeces; pulse feeble. March 23d.—Bowels have been twice freely opened. Appearance much improved. Pulse 108 per minute, full. Same ten derness of abdomen. March 24th.—Still slight soreness on pressure over the abdomen, but no acute pain ; right and left sides of abdomen perfectly tympanitic; tongue clean; pulse strong. March 25th.—An abundant deposit of lithates appeared in his urine to-day ; general appearance still improving. March 26th.—Urates still continu- ing to be deposited in urine. Chlorides still absent. Bowels moved naturally yester- day. There is no pain complained of on pressure being applied to the abdomen. Tongue moist, but covered with a slight white fur. Pulse strong. Appetite much improved; has little thirst, and expresses himself as being altogether much better. March 21th.—To-day the chlorides have returned to urine, though scantily. Lithates have disappeared. Tongue still covered with a whitish fur, but moist. Bowels opened naturally to-day. Altogether progressing favorably. From this time he gradually recovered; the strength, though supported by nutrients and wine, returning slowly. Dismissed quite well, April 9th. Commentary.—There could be no doubt as to the intensity of this case of peritonitis, which was ushered in by strong rigors, presented great febrile excitement with agonising local pain, and was accompanied by total disappearance of the chlorides from the urine. The cough and vomiting added greatly to his sufferings, and increased his prostration. Yet without antiphlogistics—for three leeches applied to the abdomen before admission will surely not be regarded as such—the case was con- ducted to a successful conclusion. This was favored by the previous good health of the patient, the absence of any serious complication, the opium, and the support he received throughout from nutrients and restoratives. Case XCIIL*—Acute Peritonitis from bursting of Graafian Vesicles into the Peritoneum—Pleurisy—Interlobular Pneumonia. History.—Margaret M'Guire, aet. 21, a milliner, native of Edinburgh—admitted September 27th, 1855. Had enjoyed good health until the 21st of the month, when, being sent out on a message, while walking she suddenly experienced a sensation as of a stone being dropped into the pelvis (so the patient describes her feeling), imme- diately followed by intense pain. She went immediately to bed, but was prevented from sleeping by the intensity of the pain, which increased in severity. At first felt only in the lower part of the abdomen, it gradually spread upwards toward the upper part of the cavity, but has again, within the last day or two, become concentrated in the lower and right part of the hypogastric region. Symptoms on Admission.—On admission her appetite is entirely lost. The tongue cannot be seen, owing to an old anchylosis of the lower jaw. Lips dry and cracked, with sores on them in places. Vomiting, which greatly aggravates her pain, has fol- lowed every attempt to take food since the beginning of the attack. Abdomen some- *Reported by Mr. Alexander Simpson, Clinical Clerk. PERITONITIS. 547 what swollen. The hypogastric region is dull on percussion. Diarrhoea has continued ever since she took a dose of castor oil four days ago. Pressure causes intense pain on every part of the abdomen. The breathing is hard and irregular, entirely thoracic in character. Respiration 24 per minute. No cough. No dulness on percussing the chest, as far as can be determined; though examination is difficult, owing to the ex- treme pain which any movement causes the patient. Pulse 124, full and thrilling. Menstruation had been suspended for two months previously, but has come on pro- fusely within the last two days. Has frequent desire to pass water, which is voided in small quantity, attended with great heat and uneasiness. Face flushed; expression anxious; severe headache. Applicentur hirudines xv abdomini. To be followed by hot fomentations. Tfc Pulv. Opiigr.yi; Conserv.Rosar.q.s.,utfiantpU.v'y, Capiat unam tertid qudque hord. Progress of the Case.—Oct. 1st.—The patient has regularly taken the pills of opium; is in a very weak state; breathing labored; pulse 154. Both purging and vomiting have in a great measure ceased. Conjunctivae slightly tinged yellow. To take strong beef-tea, and Sherry % iij. Oct. 2d.—Patient appears to be sinking; pulse 160, quick and fluttering; respiration laboridus and painful; skin cold and moist; abdominal tenderness great; swelling in abdomen rather increased; bowels open this morning; stool free and faeculent. Urine acid; sp. gr. 1020; deep orange colored, contains a small amount of albumen, is tinged green by nitric acid. Crystals of triple phosphate seen under microscope. Oct. 3d.—Patient continued to sink during the night, and died this morning. Sectio Cadaveris:—Forty-eight hours after death. The tissues were well nourished: more than one inch of fat in abdominal parietes. Thorax.—Heart and pericardium healthy. The entire surface of each pleura was covered by an exudation of recent lymph. This lymph was in some places thin, in others nearly a line in thickness; it was soft, and had an unhealthy appearance, being of a dirty yellowish-green color. There was no fluid effusion in either pleura. Left lung, when cut into, presented nothing remarkable. The lower third of the right lung presented a singular marbled appearance, in consequence of each pulmonary lobule being surrounded by a layer of coagulated exudation, generally about one-eighth of an inch in thickness. Careful examination demonstrated in fact that the interlobu- lar vessels had poured forth an exudation, which had coagulated outside the lobules, which were cedematous, but not hepatized. Abdomen.—The whole surface of the peritoneum was coated with lymph, but there was no collection of serum. The lymph in some places was in flakes, in other situa- tions it was of the consistence of thick gruel, closely resembling pus. The coils of the intestines were glued together by lymph; but the exudation was most abundant near the pelvis. The whole of the intestinal canal was carefully removed and examined; there was no appearance of ulceration or of perforation. Appendix vermiformis nor- mal. The liver was of a brick-red color, and was decidedly softer than natural. The kidneys likewise were somewhat softened, but otherwise appeared healthy. The spleen was of pulpy consistence, and broke down under the slightest pressure. The uterus was healthy. The right ovary was about the size of a walnut; on being cut into, its stroma was found somewhat softened; it contained an unusual number of graafian vesi- cles. Externally there was adherent to the serous covering a layer of firm lymph, so adherent that it could only be removed with difficulty. It apparently originated from the rupture of one or more graafian vesicles, several of whieh were on the surface, large, and filled with sanguineous serum. The left ovary was the size of a small orange, and contained a cyst about the size of a walnut, filled with blood. Such of its substance as remained was of exactly the same consistence as that on the right side. The peri- toneum covering it, however, was healthy. The veins in the broad ligaments were examined, but presented nothing unusual. Commentary.—In the case of this young girl, the menstruation, after being suspended for two periods, comes back profusely; and, when walking, she experiences a sudden pain deep in the pelvis. This is fol- lowed by excessive agony and all the symptoms of acute peritonitis. She is admitted into hospital on the sixth day. Leeches and fomenta- tions are applied locally, but without any avail. A grain of opium is 548 DISEASES OF THE DIGESTIVE SYSTEM. given every third hour, but without checking the disease. She dies on the eleventh day. On dissection, both ovaries are found enlarged and cystic; the right one is firmly encrusted with recent lymph, and several cysts immediately below the layer of exudation are enlarged, prominent, and filled with sanguineous serum. The inference obviously is, that one or more of these graafian vesicles had burst into the peritoneum, instead of into the fallopian tubes, and so excited the peritonitis. The cause of the disease spreading to the right pleura and interlobular spaces could not be discovered. I have since seen three other cases of acute perito- nitis in young women, coming on exactly in the same manner, and owing apparently to the same cause, all of which have recovered. In none of these were leeches applied. In such a case, where the peritonitis was clear and evident from the first, the treatment by quietude, warm fomentations, and opium inter- nally, was indicated and put in practice. The leeches may be dispensed with. Purging rarely occurs, though it did in this instance; generally speaking, there is great constipation in peritonitis. Under such circum- stances, active purgatives should not be administered for two or three days after the onset of the inflammation, and then only the mildest remedies of that class ; or enemata may be given. Percussion, by indi- cating whether the caecum or rectum are the parts distended with faeces, will occasionally enable us to decide whether an aperient or an injection will be most appropriate. Other cases occur where, from acute symp- toms being absent and local tenderness obscure, active purgation is often practised, to the detriment of the patient. This is very apt to occur when acute peritonitis is combined with jaundice and liver disease. The treatment of such cases is most difficult, as the means requisite for over- coming obstruction in the gall-ducts are those which we should avoid in peritonitis. In cases arising from perforation of the stomach and intes- tines, the utmost caution is required (which cannot be too often enforced) before stimuli and purgatives are given. (See Cases LXII. and LXIII.) Although, in the vast majority of cases, peritonitis arises from some lesion of the abdominal organs, which, as in the present case, affects the serous membrane secondarily, it sometimes happens that no lesion to account for the inflammation can be discovered after death, although the symptoms of perforation may have existed during life. In such cases, the inspection should never be concluded without a careful examination of the appendix vermiformis, where I have seen minute perforations very apt to escape notice. This part, besides being exposed to all the ordi- nary diseases of texture, is especially liable to have impacted in it grains of wheat, barley, or other kind of seed, cherry-stones, pins, and a variety of foreign bodies, which pass readily through the other portions of the intestines, but which, in the appendix, may give rise to ulceration, per- foration, and fatal peritonitis. Although our first efforts in cases of peritonitis should be directed to relieve pain, maintain quietude, and diminish peristaltic action by means of opium, we must not lose sight of the necessity of favoring such transformations in the exudation as will cause absorption or chronic adhesions. All exhaustive remedies, therefore, are to be avoided ; and, as soon as the circumstances of the case admit of it, nourishment, and, if necessary, stimuli in moderation should be administered. PERITONITIS. 549 Case XCIV.*—Tubercular Peritonitis with great Deposit in Parietal Layer—Tubercle and Heptatization of Lungs—Pleuritis—Adherent Pericardium—Commencing Fatty Degeneration of Heart—Biliary Congestion and Fatty Degeneration of Liver—Slight Leucocythemia. History.—Elizabeth Barker, set. 17—admitted Oct. 6th, 1854; single; employed in a factory; has been ill for about eight months. In the month of February last she was attacked with a "fever," which she attributes to working in a cold and damp room. This confined her to her bed, and she was under medical treatment for two months, at the end of which time she was much better. A fortnight afterwards she was attacked with pain in the lumbar region and left side, and with a dry cough, and she did not pass so much water as usual. Her abdomen and legs also became swollen. She took medicines, which partially removed the swelling. She came to Edinburgh three weeks ago, and since then the swelling in the abdomen and legs has been gradu- ally increasing. Symptoms on Admission.—On admission, urine scanty and high colored; sp. gr. 1030 ; does not contain albumen. She has never menstruated. Complains of pain over the lumbar vertebrae, increased by pressure. Tongue moist and furred, appetite impaired. Has a sour taste in mouth, and is troubled with flatulence. Bowels costive. Cardiac sounds normal. Pulse 128, small and thready. A friction sound is audible over the inferior part of both lungs, anteriorly, posteriorly, and laterally, with dulness on percussion, and diminution of vocal thrill. In the upper part of right lung, ante- riorly and posteriorly, the respiratory murmur is audible, with slight increase of vocal resonance. Over upper part of left lung anteriorly, the natural respiratory murmur is audible, but posteriorly there is a marked increase of vocal resonance, with tubular breathing. Posteriorly aegophony at the angle of right scapula. Skin moist, of natu- ral temperature. R- Hydrarg. Protoiod. gr. vj; Ext. Hyoscyami 3 ss; Conserv. Rosar. q. s. utfiant pil. xij. Sumat unam bis die. R Sp. JEth. Nitrici § iss ; Tr. Scillm ; Tr. Digitalis aa 3 ij. M. Sumat 3 j ex aqua indies. Progress op the Case.—October 11th.—Dyspnoea continues. Pain in abdomen increased. Has been suffering from purging for the last 24 hours. To take chalk mixture with Sol. Mur. Morphia!. Oct. 14th.—Six leeches were ordered to the ster- num yesterday. To-day friction sound has disappeared. To have § ij of port wine. Nov. 1st.—The distended abdomen measures 32£ inches. Fluctuation distinctly felt. Vertical hepatic dulness 2| inches. Dull pain in hepatic and right lumbar region, but no tenderness, as it can be handled and pressed freely without causing inconven- ience. Feet cedematous. Sweats considerably. R Potass. Acetat. 3 ij; Sp. jEth. Nitrici § ss; Mist. Scillce § viss. M. Sumat § ss ter indies. Omittantur alia. Nov. 12th.—Quantity of urine much increased. Abdomen measures 31 inches. Nov. 22d.— Abdomen measures 30£ inches. Nov. 25th.—Fluid in abdomen much diminished. Swelling and tension of its walls greatly decreased. Circular measurement 29 inches. On palpation a distinct hardness may be felt in the right hypochondriac region, ex- tending into the epigastrium. Tongue dry and brown. Has been suffering from diarrhoea for some days past. The stools have of late been clay-colored, and slight jaundiced tint of skin has made its appearance. Urine contains bile, and is slightly coagulable by heat and nitric acid. Blood presents a slight increase in number of white corpuscles. To have a starch enema with Tinct. Opii. Nov. 26th.—Much worse. Skin cold. Face sunken and pale. She lies on left side; any other position causes great dyspnoea. Respiration 36 to 40 per minute. Coarse crepitation may be heard over the whole right side. Pulse 120, very weak. Diarrhoea continues, but stools this morning were faeculent. Urine dark brick-red; sp. gr. 1012, with some traces of bile. Not a trace of chlorides present. To have the enema repeated immedi- ately, and 3 oz. of brandy. Nov. 21th.—She gradually sank, and died to-day at 10 p.m. Sectio Cadaveris.— Twenty-seven hours after death. External Appearances.—Body emaciated. Abdomen somewhat distended. Thorax.—The pericardium was universally adherent. The adhesions were firm, and were broken down with difficulty. The valves of the heart were healthy, but the muscular substance was of brownish-red color, and rather softer than natural. The size of the heart was normal. There were firm old adhesions over the upoer lobe of the right lung. Over the lower lobe there was a thin layer of recent lymph. * Reported by Mi-. Almeric W. Seymour, Clinical Clerk. 550 DISEASES OF THE DIGESTIVE SYSTEM. Between the diaphragm and the base of the lung was a pouch containing about six ounces of turbid fluid, in which floated some flakes of lymph. The whole lung felt firm and dense. When cut into, it presented a somewhat granular surface of a red color, was scarcely crepitant, broke down readily, and some portions of it sank in water. Scattered through it were a number of yellow masses, from the size of millet seed to that of a small pea. They were of cheesy consistence, and were pretty readily broken down. They were scattered equally through the pulmonary substance, and were not more abundant at the apex than elsewhere. None were softened. The left lung was universally adherent, but there was no recent lymph. The lung felt firm, and when cut into presented altogether the same appearance as the right lung. The same yellowish masses were scattered through it. The bronchial glands were enlarged, and when cut into were found to contain yellow, cheesy, tubercular matter. Abdomen.—The cavity of the abdomen contained about a gallon of yellowish, toler- ably clear fluid. The parietal peritoneum was very much thickened by a deposit, varying from about one line to half an inch in thickness. It was of a yellowish color, but, on looking closely into it, numerous opaque points, of the size of pins' heads Or so, were seen separated from one another by a clear substance. On cutting into the deposit, this appearance was still more distinct. Numerous blood-vessels were seen on its surface and in its substance; and on the former were numerous particles of ex- travasated blood of a bright red color. The deposit was of firm consistence. The coils of the intestines were firmly adherent by tolerably firm lymph. Their coats were softened, so that, in endeavoring to separate the adhesions, they tore readily. On looking closely at the surface of the intestines, numerous small, semi-transparent, yellowish-white deposits were seen on the serous surface, and these presented all the usual characters of tubercle. The mucous coat of the intestines was healthy. The capsule of the liver was thickened, and the upper and anterior part of it was adherent to the diaphragm. The liver was externally of a yellow orange color. On cutting into it numerous opaque yellowish-white masses, varying from the size of a pin's point to that of a millet seed, were seen surrounded by deep orange-colored matter. The surface of the section was quite smooth; the tissue of the liver was rather softer than natural; and there did not appear to be any increase in the amount of fibrous tissue. The liver was small, and weighed 2 lb. 7 oz.; sp. gr. 1051. The gall-bladder was small, its coats were thickened, and it was bound down to the liver by fibrous tissue. It contained about two drachms of orange-colored bile. The spleen was natural. Mesenteric and lumbar glands enlarged, of white appearance, of a smooth surface on section, yielding a copious opaque juice on pressure. The kidneys presented nothing unusual. Microscopic Examination.—The muscular fibres of the heart had lost, to a cer- tain degree, their striated appearance, which was replaced in some by granular fatty mattter. The masses of deposit in the lungs presented all the usual characters of tubercle. On examining the thickened peritoneum, large groups of tubercle corpus- cles and granular matter were seen to be surrounded and isolated by fibrous tissue. The pale, opaque-looking points in the liver, consisted of accumulations of fat, partly free, partly in hepatic cells. The surrounding parts were loaded with yellow biliary matter. There was no increased quantity of fibrous tissue. The tubes and cells of the kidneys appeared quite natural. Commentary.—This is a characteristic case of so-called tubercular peritonitis, associated with pulmonary tubercle and various other lesions. In a practical point of view, it is to be remarked that the symptoms were wholly different from those in the previous case. There was no abdominal tenderness, no inflammatory fever—and, notwithstanding the large amount of lymph exuded, some of it recent, all the symptoms were those of ascites dependent on atrophy of the liver. In some cases of this disorder, the peculiar doughy feeling communicated to the hand, and the roughened friction perceptible on moving the two peritoneal surfaces over the other, give an indication of the nature of the disease— the latter symptom was absent in the present case in consequence of the accumulation of fluid. Occasionally the amount of tubercular exudation is very great; I have seen it matting together all the intestines and abdo- minal viscera in a layer varying from a half to an entire inch in thickness. PERITONITIS. 551 In such cases also it frequently happens that whilst the abdomen is loaded with tubercle, the lungs are comparatively free from it. The mesenteric and lumbar glands in these cases are very apt to be- come hypertrophied, and the blood to contain an unusual number of colorless corpuscles. In a man, James M'Arthur, who died in Paton's Ward during the summer of 1857, these glands were enlarged. There was also an enormous collection of tubercular exudation in the abdomen, which on examination was found to form a layer from one-half to an inch in thickness, glueing the intestines and abdominal viscera together. On examining a drop of his blood under the microscope in the usual way, during life, from twenty-five to forty colorless corpuscles could always be counted in the field of the instrument. (See Leucocythemia.) Case XCV.*—Cancer of various Abdominal Organs and of the Lungs, producing Symptoms of Peritonitis. History.—Christina Galbraith, aet. 52, a fish-cleaner, at Newcastle, single—admit- ted November 29, 1854. The patient states that, until nine months ago, she enjoyed good health, since which time her strength has been diminishing. She has been de- cidedly ill for the last three months. Her first symptoms were pain in the epigastrium, a feeling of cold, great thirst, anorexia, sickness, and severe night-sweats. The pain in the epigastrium has gradually increased up to the present time. About ten weeks before admission, she noticed that her abdomen began to swell, and the swelling has since gradually increased. Her feet have, for the last five years, evinced a tendency to oedema towards evening, in consequence, as she thinks, of her work requiring her to be much in the erect position, and lately they have become more swollen. Four weeks ago she had an attack of jaundice, accompanied by severe pain in the lumbar and right hypochondriac regions. The color of the stools is not known, but she thinks her bowels were regular at the time, although she is habitually subject to constipation. A week after its appearance, her bowels became very loose; the stools were faeculent and abundant. On one occasion she passed a considerable quantity of blood, accompa- nied by what she describes as "great lumps of strings," but of the color of which she has no idea. At this time she had no vomiting, but felt great pain over the whole of the abdomen, which became very swollen and tense. She improved under medical treatment; the bowel complaint disappeared, and the pain in the abdomen abated. But she does not know how long the attack lasted. During its continuance she also suffered from vomiting; the matters ejected were sometimes of a green, at others of a coffee- ground color. The bowel complaint and the pain returned with great severity on her voyage from Newcastle to Edinburgh. She also vomited considerably, and was brought to the Infirmary in a state of great exhaustion on the evening of the 29th of November. Symptoms on Admission.—On admission, she complained of great pain over the epigastrium and right hypochondrium, and generally all over the abdomen; face very anxious; pulse small and quick. Ordered Wine and Brandy, Tannin and Opium Pills, and four Leeches to right hypochondrium.. Next day was carefully examined. Face and conjunctivae have a yellowish tinge; countenance anxious, but speech is clear and com- prehension quick. She complains both of a continuous and a shooting pain, worse over the epigastrium and over the left side of the abdomen, in the course of the descending colon. The pain felt last night in the right hypochondrium has been diminished by the leeches, which bled well. She lies with greatest ease on the right side, and feels great pain when she assumes the supine position. The abdomen is exceedingly tender on pressure ; it is swollen, tense, and tympanitic, permitting nothing deep-seated to be felt. Pungent heat, and dryness of skin over its surface. Tongue white, with prominent papillae, pale, smooth, and glossy at tip and edges. Complains of constant bad taste in mouth; has a burning pain at epigastrium, and most intense thirst, but cannot take cold water, as it causes immediate vomiting, though she does not otherwise feel sick. Appetite entirely gone; bowels have not been moved since her admission. Urine diminished in quantity, high-colored, with a deposit of lithates; the chlorides are present; sp. gr. 1014; she has a sense of heat in passing it. Catamenia last appeared Reported by Mr. 0. Beaujeard, Clinical Clerk. 552 DISEASES OF THE DIGESTTVE SYSTEM. about a month ago. Pulse 108, small and weak. Apex of heart beats between fifth and sixth ribs; transverse dulness normal. Sounds normal. Breathing mostly thoracic; respirations 32 per minute; cannot take a full breath without pain; has a short hacking cough. Chest expands equally, but imperfectly. Percussion good, both anteriorly and posteriorly; respiratory murmurs natural. Has headache, tinnitus aurium, and muscae volitantes. Feels sick and giddy on sitting up. There is oedema of the feet, ankles, and legs. To have wine 4 oz., and in the evening a Turpentine and Assafoztida enema. Progress of the Case.—December 1st.—The enema was followed by two faecu- lent and hard stools. Pain in the abdomen considerable—most felt below the margin of the right false ribs. Complete anorexia. Great thirst; pulse 104, small and hard. Dec. 2d.—State much the same ; bowels not again opened. Pain in the abdomen bein" increased, she was ordered six more leeches to the right hypochondrium, and the follow- ing diuretic mixture—ty.Potassw Acetatis 3 ij ; Sp. ^Eth. Nitrici §ss; Mist. Scillae, | vss. M. | ss to be taken three times a day. Dec. 5th.—Breathing natural; abdo- men not so tense and hot; pain greatly diminished; appetite not improved; stoola dark but healthy; pulse 96, small and weak. Dense deposits of lithates in urine. Dec. 10th.—Pulse 92, very small and weak. No thirst; appetite not improved, abdo- men less tense—fluctuation may be distinctly felt. Pain less—most severe on left side. Dec. 18th.—Passes very little urine; it is high-colored, and deposits lithates abun- dantly. Abdomen less tense—measures 33 inches in circumference. It is tympanitic, and fluctuation may be felt. Feet oedematous; bowels regular; no appetite, great thirst; slight catching of the breath. R Pulv. Digitalis gr. iij ; Pulv. Scillce gr. vj; Ext. Taraxaci q. s., ut fiant pil. vj. Sumat unam bis indies. Omittantur alia. Dec. 19th.—Urine much increased in quantity; is very high-colored; deposits lithates. Dec. 20th.—Great pain complained of in lumbar region. Yellowish tinge of complex- ion increasing. To apply to the abdomen the Spongio-Piline soaked in Inf. Digitalis of four times the usual strength. Dec. 21st.—The Spongio-Piline has relieved the pain in the abdomen. Breathes easier. Thinks her urine diminished in quantity. It is of a deep copper color. Has vomited her breakfast for the last two days, but is not sick otherwise. Bowels regular, appetite not improved; pulse 108, weak. Dec. 23d.— Vomiting more frequent: is much troubled with flatulence; tongue pale, smooth, and glossy; bowels regular. Dec. 25th.—Tr. Iodinei to be painted over the abdomen. Dec. 21th.—The iodine caused her great pain, which was, however, relieved by warm fomentations. The swelling of the abdomen and tympanitis, the cough, and the ex- pectoration, have increased; breathing slightly laborious. R Sp. ^Eth. Sulph. 3 iij; Sol. Mur. Morph 3 j; Mist. Scillce % iiss. To be taken in half ounce doses when the cough is troublesome. Dec. 30th.—Abdomen measures 34 inches in circumference. Bowels regular ; percussion normal over chest; mucous and sibilant rales heard on auscultation. Coughs much ; expectoration abundant, purulent, and tenacious; pulse small and weak; legs and feet very oedematous; urine as before. Jan. 2d.—Jaun- diced tint of skin is growing deeper; distension of abdomen from tympanitis increased; pulse rapid and thready; vomits all her food immediately after taking it, together with a quantity of black matter; thirst great; stools pale-colored but consistent. To omit the Squill and Digitalis Pill, and to take Potass. Bitart. 3j ter indies. Jan. 4th.— Jaundice increases; urine very small in quantity, and contains bile. Swelling of ab- domen augmented; great protrusion of lower ribs, but breathing is not much affected. Vomiting continues. There is oedema of feet, legs, and hands; she is getting decidedly weaker. Pulse 96, steady and weak. Jan. 5th.—Died this morning at 2 a.m. Sectio Cadaveris.—Fifty-eight hours after death. The body emaciated; the surface of a moderately yellow tinge; abdomen much distended and fluctuating. Thorax.—The pericardium and heart were healthy; there were a few slight old adhesions on the left side of the chest; the left lung, when removed, had an irregular feeling from the presence of a number of masses, some immediately under the pleura, others embedded in the pulmonary tissue; the masses visible externally had a cir- cumference equal to about that of a fourpenny piece; their margins were slightly prominent, while they were depressed or flattened in the centre; they appeared of a greyish-white color, and felt firm and hard; on cutting into the lung, pretty nume- rous masses similar in size could be seen scattered through it; they were generally of a white or greyish-white color, while some were yellowish, as if stained by biliary matter; most of these masses felt tolerably firm, but yielded on pressure a small PERITONITIS. 553 quantity of a glairy juice; others, however (which were more opaque-looking than the rest), crumbled down easily under the fingers. The right lung was very densely adherent throughout externally; it presented masses similar to those found in the left lung, and others could be felt in its substance; it was not cut into, but was sent entire to the university museum; the pulmonary tissue intervening between the masses was quite healthy. A few of the bronchial glands at the root of each lung were a little enlarged, and when bisected were found to contain a substance like that met with in the tumors of the lungs. The bronchi were unaffected. One gland in the anterior mediastinum immediately under the upper part of the sternum was of the size of a walnut, and on being divided, was found converted into a mass of almost cheesy consistence, of a yellow color, mottled by the presence of a good deal of black pigmentary matter. Abdomen.—The cavity of the abdomen contained about a gallon and a half of a clear yellowish fluid. Peritoneal membrane everywhere healthy. The liver, which was much enlarged, presented a very irregular appearance, in consequence of the projection from its surface of numerous masses of a whitish-yellow color, varying from the size of a pea to that of the fist; some were rounded, others of a very irre- gular form. Only a very few of these masses presented any central depression. When cut into, the substance of the liver was found, to a great extent, occupied by a similar matter; at some places it occurred in small isolated masses, but in general it was found infiltrated in large patches. It was of a yellowish color; some parts of it, however, were opaque, while intervening portions were clear and semi-trans- parent ; other parts, again, were intermediate between these conditions; the matter was generally tolerably firm, but the more opaque parts had a tendency to crumble down. The hepatic tissue itself was of a yellowish color, and moderately firm. The weight of the entire liver was 7 lbs.; behind the liver a mass of enlarged glands surrounded and compressed the vena cava, the gall-bladder, and common duct; the vena cava was somewhat diminished in size: the gall-bladder was much con- tracted, being little larger than an almond, and contained scarcely any bile; on passing a probe from the gall-bladder along the cystic duet, the latter was found quite occluded, a little before ita point of junction with the common duct; a probe was passed from the duodenum along the common duct, but both it and the Hepatic duct were compressed and contracted; the enlarged glands, when cut into, were found converted into firm yellowish masses, quite similar to those met with elsewhere. The pancreas was healthy; the stomach felt indurated towards its pyloric end, and on being cut into, a large ulcer was found near the pyloric orifice; it was of an oval form, about 3^- by 2\ inches, its longest diameter being from above downwards; its right margin was about an inch from the pylorus. The ulcer had a hard thickened base, and a very irregular surface from the presence of numerous fungating excrescences of a greyish-white color. The margins of the ulcer were elevated above the surrounding mucous membrane, but were irregular looking as if they had been gnawed by some animal. There was no perforation. The stomach and the duodenum otherwise healthy. Some of the gastric lymphatic glands, particularly some of those connected with the lesser curvature, were enlarged and cancerous. The spleen was natural. The kidneys, when cut into, were of a yellowish color: their surface was a little irregular, apparently resulting from old cysts; a few cysts were seen in the surface, and also in the cortical portion; several of the lumbar glands, lower down than the mass found behind the liver, were enlarged and similarly affected. The uterus and ovaries were healthy. Microscopic Examination.—On examining a little of the juice squeezed out of any of the masses above described, tolerably large nucleated cells were found. Many of them presented the usual appearance of cancer-cells; others, however, were small, and many nuclei were seen free. In the opaque portions, the cells were less distinct, and there was a large quantity of fatty matter. The cells of the liver con- tained a good deal of biliary matter, but they were otherwise quite healthy. The kidneys, when examined microscopically, also appeared healthy. Commentary.—This subject of cancer of the lungs, liver, stomach, and other organs, when she entered the clinical ward, presented all the symptoms of acute peritonitis, including great tenderness, with disten- sion of the abdomen, fever, and increase of urates in the urine. There was, however, no evidence, on palpation, of the nodular swellings found after death; these were masked by the accumulation of fluid and tym- 554 DISEASES OF THE DIGESTIVE SYSTEM. panitis. Neither did physical signs indicate the cancerous deposition in the lung, it being so diffused as not to occasion any marked abnormal respiratory symptoms; such as did exist were explicable by the abdo- minal disease. The facts presented in the three last cases indicate the uncertainty of our diagnosis in abdominal diseases. In the first, it is true, the symp- toms corresponded with the acute peritonitis of authors; but in the second there were no such symptoms, though there was abundance of exudation; while the third case presented all of them in a marked and characteristic degree, in connection with cancer of the abdominal organs, and effusion of serum. I never saw a case which better satisfied me of the insufficiency of mere symptoms, for the purpose of arriving at an exact knowledge of a patient's real disease. The history of this case, it is true, indicated the existence of some chronic disease, but all the positive symptoms, after her admission, including extreme tenderness of the abdomen, its distension, tympanitis, constipation, high fever, vomit- ing, etc., pointed out that the chronic disease of the stomach and other organs had terminated in acute peritonitis. Yet, on examination, peri- tonitis there was none, but only serous effusion, or ascites, evidently resulting from the organic disease of the liver obstructing the abdominal circulation. When contrasted with the last case, in which the peri- toneal membrane was covered with lymph, the present one, where it was healthy, exhibits a remarkable discordance with systematic descriptions of disease. The true exudation had not one of the so-called symptoms of that lesion, whereas, in the last case, there was every symptom, with a perfectly sound peritoneum. I have recorded therefore this case at great length, because the acute symptoms will speak for themselves, and because, when compared with some remarkable cases afterwards to be given of pleuritis without the usual symptoms, it serves, in my opinion, to convince us that many of our existing notions as to the pathology of acute diseases require to be modified. For other examples of peritonitis, see Cases LXVII. and LXXXVII. Case XCVL*—Cancerous Peritonitis—Ascites and Hydrothorax— Paracentesis Abdominis—Arrested Phthisis Pulmonalis. History.—Margaret Purdon, aet. 63, a widow, has had two children—admitted December 15th, 1856. Three years ago she had profuse haematemesis, accom- panied by loss of blood per anum, which caused faintness. In a few days, however, she quite recovered, and remained perfectly well until three months ago, when she first observed that the lower part of the- abdomen was swollen, but not painful. About a fortnight afterwards she experienced severe pain in the left lumbar region, together with a sensation as of cold water trickling down her left thigh as far as the knee. Two months after the first symptoms had shewn themselves, the abdo- men had become gradually much distended, and she experienced a " dead pain" in the epigastric region, which, she says, was constant, but not aggravated by pres- sure, and caused great shortness of breath. Simultaneously with this epigastric pain a scantiness and turbidity of the urine appeared, and a day or two subsequently both feet and legs became very much swollen, the right one especially so. During the last fortnight she has taken several doses of rhubarb and magnesia, the purgative action of which has been followed by considerable alleviation of her symptoms, and diminu- tion in the size of the abdomen, and of the dropsical swelling of the inferior extremities. Symptoms on Admission.—The abdomen is so distended as to measure at the epigastrium 29^, and at the umbilicus 35 inches round. It fluctuates on palpation, but there is no pain on pressure. In every position the lower portion of the abdo- men is dull, and the upper tympanitic on percussion. No tumor can be detected, * Reported by Mr. Alexr. M'Leod Pemberton, Clinical Clerk. PERITONITIS. 555 nor can the amount of the hepatic dulness be accurately determined. The tongue is covered with a white fur on the right side, and is perfectly clean on the left. She has a good appetite, but cannot eat much on account of the uneasiness it occasions in the epigastrium—a symptom from which she is now seldom free. The bowels are open naturally every other day. No flatulence. There is considerable dyspnoea; a slight cough, but no sputum. Percussion is resonant over the whole chest. At the apex of the left lung expiration is prolonged and hard, and the vocal resonance increased. Pulse 85, of good strength. Heart's size and sounds normal. The face is much emaciated and pale. Both feet and legs somewhat oedematous, the right one most so. Does not sleep well on account of the dyspnoea. Urine sp. gr. 1012; con- tains phosphates in solution, but no albumen. Progress of the Case.—January 5th.—Since coming into the house she has had an occasional dose of castor oil, and her symptoms have on the whole been much alleviated. There is, however, great orthopnoea at night, and she says it is easier to fie on the left side. A careful examination to-day has determined that there is great dulness on percussion over the lower half of right lung, and that the respira- tory murmurs there are audible. The abdomen now measures at the epigastrium 3H, and at the umbilicus 37 inches. Pulse 92, feeble. Passes urine, loaded with phosphates, freely. To have extra nutrients, and four ounces of wine daily. Jan- uary 12th.—In consequence of the great dyspnoea, which is daily increasing, para- centesis of the abdomen was performed, and 190 ounces of a pale, greenish-yellow fluid were drawn off. This fluid was of the sp. gr. 1012, and formed a solid, gela- tinous mass on the addition of heat. On standing it became slightly turbid, but exhibited nothing but a few scattered blood corpuscles under the microscope. The operation was followed by a tendency to syncope, which was removed by the free use of port wine and brandy. Jan. 13th.—Feels greatly relieved by the operation. Several nodulated swellings can now be felt under the flaccid abdominal integuments, especially on the left side. Jan. 14th.—Though greatly relieved, complains of great weakness. Jan. loth.—Though liberally supplied with stimulants, died this morning at half-past two, apparently from exhaustion. Sectio Cadaveris.—Thirty-five hours after death. External Appearances.—Great emaciation. Abdomen flaccid, she having been tapped a short time before her death, and 190 ounces of serum removed. Thorax.—The external surface of the pericardium contained a number of can- cerous nodules, varying in size from a pepper-corn to that of a small bean, of a white and pinkish-white color. The internal layer of the pericardium and the heart were healthy. The right pleura contained about four pints of serum. The lung was compressed and pushed up against the spine. Its upper fourth was Bpongy, but mo3t of the three inferior fourths were carnified, and contained little air. Scattered over the pulmonary pleura were numerous cancerous masses, of a rounded or oval form, varying from the size of a pin's head to that of a split pea. They were of a clear white color, rose abruptly from the pleura, and were gene- rally half a line or a fine deep. Some of them had a slight central depression, and in many, blood-vessels could be seen. The costal pleura had similar nodules, and flat patches covering it, some of the latter being the diameter of a shilling. The apex of right lung was strongly puckered, and contained several concretions surrounded by dense pigment; the rest of its tissue was healthy. The left lung was more volu- minous than the right. The pleurae at the apex were adherent and thickened. On section this was found to correspond to an old tubercular cavity of the size of a small filbert, also surrounded by dense tissue loaded with pigment. The substance of the lung was otherwise healthy, and the pleurae generally presented only a few small cancerous masses scattered over them, similar to those on the opposite side. The bronchial and mediastinal glands were healthy. Abdomen.—There were two or three pints of clear fluid in the abdominal cavity. The whole of the peritoneum (parietal and visceral) was studded over with cancerous masses. The great omentum was shrivelled, drawn up, and converted into a thick mass of opaque, moderately firm, cancerous matter, the substance of which contained numerous yellow opaque points. The transverse colon was dragged up towards the stomach, and much compressed by this mass. All the adjoining veins were greatly congested. The peritoneum covering the lower surface of the diaphragm was lined by a thick layer of cancerous matter, which appeared to have been deposited in nodules, which were so thickly placed as to have run into one another, forming a layer about two lines thick. Over the other parts of the peritoneum, nodules and small 556 DISEASES OF THE DIGESTIVE SYSTEM. patches of cancerous matter were scattered about. The whole of the mesentery was studded with little masses from the size of a grain of sand to that of a pepper-corn. Similar masses were found in the serous coat of the small intestines. The meso-colon and meso-rectum were thickened and covered with cancerous masses. The uterus, urinary bladder, and ovaries were matted together by cancerous exudation. None of the abdominal viscera or glands were involved in the cancerous disease, which was exclusively confined to the serous membrane. Microscopic Examination.—The different nodules of cancer presented all stages of development and disintegration of the cancer cell; in some places numerous naked nuclei; in others large compound cells; in others, debris and fatty degeneration, forming yellow masses of the reticulum.. Commentary.—The insidious approach and development of so large an amount of cancerous exudation on the peritoneum is worthy of ob- servation. It is very possible that the disease existed three years previous to her admission into the house, when the hemorrhage occurred from the mucous membrane of the stomach and bowels. But she rapidly recovered, and remained well until dropsical symptoms supervened, in consequence of the pressure of the indurated cancerous masses on the abdominal veins inducing effusion. At no time was there any general fever, pain, or tenderness on pressure. In this respect the case strongly contrasts with the last. Here, with extensive disease of the peritoneum, there were no symptoms of peritonitis; there, with the peritoneum per- fectly healthy, violent symptoms of peritonitis were manifested. Indeed, the only symptoms occasioned, were those resulting from pressure on the lungs by the accumulation of serum in the peritoneal and right pleural cavities. The orthopncea thus occasioned was so distressing as to induce me to have the abdomen tapped; and it is worthy of remark that, although thereby the greatest relief was experienced, she rapidly sunk. Indeed, it seldom happens when, in ascites resulting from organic disease, this operation is had recourse to, that death is long delayed—a remark- able proof of the fallacy of that system which is based on the treatment of symptoms. (See p. 517.) In a case very similar to the above, occurring in a young man, aet. 20, admitted under my care during the winter 1858, there was the same universal cancerous peritonitis, and the same distension of the abdomen from fluid, without local tenderness. Instead of " nutmeg liver "—that is, incipient cirrhosis—however, the organ presented the disease in a more advanced condition. Difficulty of breathing, nothwithstanding, was never so urgent, the pleuras being healthy, and three weeks before death, the abdominal tension spontaneously disappeared, so as to enable me to feel the nodulated omentum through the abdominal walls, and thus determine the nature of the case. He was a groom, and the first symp- tom of the disease appeared in the form of varicose veins in the lower extremities. These on admission were enormously swollen and tortuous, especially in the popliteal and inguinal regions, where they formed tumors the size of pigeons' eggs. After death the swellings were found to consist of distended veins filled with firmly clotted blood of a red brick color. The cause of the varicosities in the extremities was the pressure occasioned by the tight and thickened omentum over the ex- ternal iliac veins, just before they passed under Poupart's ligament. It results that the cancer must have existed in the abdomen when he was actively pursuing his employment, for the varicosities appeared a year before his admission. In both cases the ascites may have been mainly owing to the hepatic disease. (See also Case LXXXVI.) SECTION VI. DISEASES OF THE CIRCULATORY SYSTEM. Before proceeding to narrate and comment on lesions of the heart and large vessels, allow me to remind you of some of the rules which the laborious researches of many able men have established for your guid- ance in the diagnosis of cardiac diseases. They are as follows : 1. In health, the cardiac dulness, on percussion, measures, imme- diately below the nipple, two inches across, and the extent of dulness beyond this measurement commonly indicates either the increased size of the organ or undue distension of the pericardium. 2. In health, the apex of the heart may be felt and seen to strike the chest between the fifth and sixth ribs, immediately below and a lit- tle to the inside of the left nipple. Any variations that may exist in the position of the apex are indications of disease either of the heart itself or of the parts around it. 3. A friction murmur, synchronous with the heart's movements, indicates pericardial or exo-pericardial exudation. 4. A bellows murmur with the first sound, heard loudest over the apex, indicates mitral insufficiency. 5. A bellows murmur with the second sound, heard loudest at the base, indicates aortic insufficiency. 6. A murmur with the second sound, loudest at the apex, is very rare, but when present it indicates—1st, Aortic disease, the murmur being propagated downwards to the apex; or, 2d, Roughened auricular surface of the mitral valves; or, 3d, Mitral obstruction, which is almost always associated with insufficiency, when the murmur is double, or oc- cupies the period of both cardiac sounds. 7. A murmur with the first sound, loudest at the base, and propa- gated in the direction of the large arteries, is more common. It may depend—1st, On an altered condition of the blood, as in anaemia; or, 2d, On dilatation or diseases of the aorta itself; or, 3dly, On stricture of the aortic orifice, or disease of the aortic valves—in which case there is almost always insufficiency also, and then the murmur is double or occupies the period of both sounds. I have also seen cases which satisfy me that it may occasionally depend on roughness of the ventricular sur- face of the mitral valves, and on coagulated exudation attached to the internal surface of the heart. 8. Hypertrophy of the heart may exist independently of valvular disease, but this is very rare. In the vast majority of cases it is the left ventricle which is affected, and in connection with mitral or aortic 558 DISEASES OF THE CIRCULATORY SVSTEM. disease. In the former case the hypertrophy is uniform with rounding of the apex; in the latter, there is dilated hypertrophy, with elongation of the apex. Attention to these rules alone will, in the great majority of cases, en- able you to arrive with precision at the nature of the lesion present. In cases in which there may be any doubt, you will derive further assis- tance from an observation of the concomitant symptoms such as—1st The nature of the pulse at the wrist; 2d, The nature of the pulmonary or cerebral derangements. Thus, as a general rule, but one on which you must not place too much confidence, the pulse is soft or irregular in mitral disease, but hard, jerking, or regular in aortic disease. Again, it has been observed that cerebral symptoms are more common and urgent in aortic disease, and pulmonary symptoms more common and urgent in mitral disease. I have purposely said nothing now of diseases of the right side of the heart, and of a few other rare disordered conditions of the organ, because I am convinced that an appreciation of the rules above given is the best method of enabling you to comprehend and easily detect any exceptional case which may arise. In truth, however, I have remarked in our examinations at the bedside that your difficulty is, not how to arrive at correct conclusions from such and such data, but how to arrive at the data themselves. You have to determine—1st, by percussion, whether the heart be of its normal size or not; 2d, Whether an abnor- mal murmur does or does not exist; 3d, If it be present, whether it accompanies the first or second sound of the heart; and 4thly, At what place and in what direction the murmur is heard loudest. These points ascertained, the conclusion flows from the rules previously given, and must ever essentially depend upon the existing knowledge of physiology and pathology. But no instruction on my part, no reading or reflection on yours, will enable you to ascertain these facts for yourselves. In short, nothing but percussing the cardiac region with your own hands, and carefully listening to the sounds with your own ears, can be of the slightest service, and the sooner you feel convinced of this truth the sooner are you likely to overcome these preliminary difficulties. This is the reason why a series of cases assembled in the ward of an hospital is so valuable. By careful examination of them, you can at once convince yourselves of the accuracy of the facts affirmed by others to exist, re- flect on the probable correctness of the diagnosis formed at the bedside, watch the various complications and the effects of treatment, and finally, observe how, in the fatal cases, by following the rules given, the ac- curacy of the diagnosis has or has not been confirmed by post-mortem examination. After you have made yourselves familiar with the ordinary forms of heart disease, you will find that occasionally very puzzling instances occur where the above rules do not apply. These exceptional cases should always be carefully studied. Indeed, this is what is now being done by the cultivators of physical diagnosis throughout Europe, with a view if possible of determining the characters which distinguish disease of the right from disease of the left side of the heart; those indicative of lesion of the pulmonary artery, of chronic forms of peri- carditis, of »pen foramen ovale, of clots in the ventricles or auricles, PERICARDITIS. 559 etc. etc. Well observed cases of these rarer diseases, however, are still too few to enable us to generalise confidently regarding them. I have frequently examined exceptional combinations of signs with the utmost care, and then been denied a post-mortem examination, or again have stumbled on rare forms of lesions after death, in cases where during life sufficiently careful and repeated examination of the physical signs had not been made to secure accuracy. I would strongly advise you to attach little importance to the record of such exceptional cases, and never to record such yourselves, unless equal care have been shown in the examination of physical signs and functional symptoms during life, on the one hand, and in anatomical investigation after death on the other. PERICARDITIS. Case XCVIL*—Acute Pericarditis—Recovery. History.—Jane Stambroke, aet. 25, servant—admitted January Yth, 1857. Six months ago she entered another ward in the Infirmary, on account of rheumatic pains in the ankle-joints. These pains were unaccompanied by general fever, and there is no evidence that the heart was then affected. During the last six weeks, however, she has experienced considerable dyspnoea, palpitation, and uneasiness over the central part of the sternum, increased by active exertion, or on ascending stairs. Five days ago, after exposure to sudden changes of temperature, she experienced towards evening a distinct rigor and increased pain in the praecordia, which compelled her to desist from working, and retire to bed at an earlier hour than usual. The next day she felt somewhat easier, but on the following one the symptoms increased in intensity, and have continued up to the present time. Yesterday evening six leeches were applied, and caused relief, which however was not permanent. Symptoms on Admission.—Cardiac impulse is faintly felt between the fourth and fifth ribs. Dulness on percussion, at the level of nipple, extends transversely four inches from the right edge of the sternum, which is its internal boundary. On aus- cultation a loud double friction murmur is audible, over and limited to the cardiac organ, loudest over the sternum and base. The systolic and diastolic sounds are in- audible in consequence of the loud friction murmurs. Pulse 108, regular and of moderate strength. She cannot lie on either side, and prefers the sitting to the recumbent posture. Says she has a slight cough, but no expectoration. Percussion elicits comparative dulness over the two lower thirds of left back, and there is audible over the same space increased vocal resonance and aegophony, without rales. Inspi- ratory murmur on right side is somewhat harsh, but otherwise normal; is sleepless in consequence of cardiac uneasiness and dyspnoea, which is considerable. Has not menstruated for the last two months, but the other functions are well performed. Warm fomentations to be constantly applied to the precordial region. Progress of the Case.—January 9th.—The pains and dyspnoea have been greatly relieved by the fomentations. No friction murmur audible. The urine densely loaded with urates. Pulse 80, soft. Nutrients with wine § ij. January 10th.—No pain or dyspnoea. Friction sound slight, and only audible over right side of cardiac organ towards the base. Transverse dulness there is diminished by a quarter of an inch. Physical signs of left lung the same. No crepitation. Chlorides in the urine abundant. January 11th.—No friction audible over heart, but cardiac sounds are distant. From this time she rapidly became well. On the 13th, marked dulness, increased vocal resonance, and aegophony much diminished over left back. On the 18th, the transverse cardiac dulness measured two and a half inches, and there remained only increased sense of resistance on percussion over left back, with slight aegophony. On the 23d, complained of loss of appetite and slight dyspeptic symptoms, which disappeared the following day. On the 27th she walked out, and did not experience so much palpitation or dyspnoea as before the present attack. Was dismissed January 31st. * Reported by Mr. McLeod Pemberton, Clinical Clerk. 560 DISEASES OF THE CIRCULATORY' SY'STKM. Commentary.—This was a pure case of pericarditis iu a rheumatic girl, in which all the symptoms and physical signs were very carefully examined. The disease went through its natural stages with great rapidity. On the fifth day, when she was admitted, there was great distension of the pericardium from exudation, with friction sounds. Then for a day these were absent, probably from the two surfaces being separated by serum. On the seventh day, distension of the pericardium began to diminish, and there was slight return of the friction. From this time there was rapid decline in the area of dulness, which on the fifteenth day was nearly normal. The local pain she experienced was before admission treated by the application of six leeches, but was still present on her admission. Warm fomentations to the part removed it at once, and constituted the only medical treatment she was subjected to in the house. Nutrients of course were given, and a little wine. The pulmonary physical signs were probably dependent on pressure of the lung backwards by the distended pericardial sac. Case XCVIIL*—Pericarditis and Endocarditis—Hydropericardium. History.—Barney Kilpatrick, aet. 25, a miner—admitted July 8th, 1850; Nine weeks ago he was suddenly seized with dyspnoea and a feeling of weight or dull pain in the cardiac region. A fortnight since this became much more acute, and has continued up to the time of admission. For five years he has been much exposed to wet and changes of temperature, but never had rheumatism. Symptoms on Admission.—Cardiac dulness measures three and a quarter inches transversely, and is limited above by the margin of the third rib. Apex beats between the fifth and six ribs, two inches below, and considerably to the right of the nipple. All over the dull region a double friction sound is heard, resembling a roughened bellows murmur, but superficial. Beyond the region of the dulness these murmurs suddenly cease. Action of the heart regular. Pulse 96, regular, small, and feeble, stronger on the right than on the left side. The slightest movement induces pain, extending from the cardiac region down the left arm to the fingers; great dyspnoea; no cough or other pulmonary symptoms; no fever; no cerebral symptoms or tendency to syncope. Treatment and Progress of the Case.—Twelve leeches were ordered to be applied to the cardiac region, and a calomel and opium pill to be taken every six hours. On the 11th, the friction murmurs were much louder at the base than at the apex. The pulse 108; feeble at left wrist; at the right wrist it had a double impulse—a pretty strong beat being followed by a weaker one. § vj of blood to be drawn from the cardiac region by cupping, and apUl to be taken every four hours. On the 13th, the breath bad a mercurial fcetor. Pulse stronger; less dyspnoea; friction murmurs more faint; pain in arm diminished. On the 14th, pulse full; slight fever; six leeches to be applied to the cardiac region, morphia draught at night. On the 15th, friction murmurs only heard at the base; anorexia; can take no food; omit calomel and opium pills. 16th.—Friction murmurs have disappeared, but there is a soft bellows murmur with the second sound, heard at the base. 18th.— Had an attack of severe dyspnoea and syncope; pulse 100, regular, but feeble; § iv of wine; cardiac dulness increased. 19th.—Orthopncea; pulse weak and fluttering; a quivering pulsation felt in the cardiac region; faintness; oedema of feet and legs. Stimulants to be freely administered. Died early in tfie morning of the 20th. Examination of the body was not allowed. Commentary.—This was a well characterised case of pericarditis. At first the endocardial murmur was masked by the friction sounds, but as these disappeared, its existence became apparent. It was observed that as the mercury affected the system, the friction murmur diminished; but there is every reason to believe that this was not so * Reported by Mr. David Christison, Clinical Clerk. PERICARDITIS. 561 much owing to absorption of the exudation, as to increase in the amount of serous effusion. To the combined effects of pressure on the heart from liquid without, and incapability of performing its function from incompetency of the aortic valves, the fatal result must be attri- buted. Since this case occurred, upwards of fourteen years ago, I have satis- fied myself that the treatment pursued was not judicious, and that the local abstraction of blood, with administration of mercury under such circumstances, is not only useless but injurious. It is true no fair com- parison can be drawn between this and the preceding case, inasmuch as here we had undoubted valvular lesion complicating the pericarditis. But this ought to be an additional reason against depletion. I have given it, however, as a fair example of cases that used formerly to be pretty common, but which now, owing to our improved pathological views applied to practice, are somewhat rare. The following case was treated differently. Case XCIX.*—Acute Pericarditis followed by Acute double Pneumonia —Recovery—Aortic Incompetence—Subsequent Articular Rheu- matism—Sudden death—Adherent Pericardium—Fatty enlaryed Heart—Thickening of Aortic Valves. History.—Jessie Douglas, aet. 22, employed in a paper warehouse—admitted November 19th, 1855. Has never been very healthy; has had several attacks of rheumatic fever, the last being about seven years ago. On the 9th current, after exposure to cold and damp, she was seized with rigors and pain in the back. These disappearing, were succeeded by pain and sKght swelling of the knees, lasting only for a few days. During all this time, though ill, she had no headache, vomiting, nor pain in the chest, but the shortness of breath and palpitation to which she is subject became aggravated. She was under medical treatment, and got purgative medicines, but was neither bled nor leeched. Symptoms on Admission.—Apex beat3 distinctly between the fourth and fifth ribs, immediately under and a little to the inside of the nipple; heart's impulse is heaving, and sensibly moves the whole mamma; it can be felt but very indis- tinctly in the normal position; there is no thrill. Transverse dulness at the level of the nipple 4§ inches. Heart sounds are exceedingly indistinct, and muffled at the apex, but no murmur is heard there. At the base the first sound is almost inaudible, but with the sound there is heard a soft blowing murmur. Pulse 80, full, regular, incompressible. Breathing is rather labored; respirations are 34 per minute, but regular; there is slight cough and no sputum. Percussion is everywhere good; vocal resonance is greater under the left than under the right clavicle; no rale is audible, but respiration is exaggerated under the right clavicle, and inspiration is blowing under the left. She speaks languidly, does not sleep, and on sitting up feels faint. She is thirsty, and has no appetite; the bowels open; catamenia are regular. Urine is neutral, sp. gr. 1018, not albuminous; deposits copious urates and phosphates; contains no chlorides. Patient lies on her back; cheeks rather flushed; the skin warm and perspiring; no pain nor swelling of any joints. Ordered half an ounce every fourth hour of the following:—R. Liquor. Ammon. Acetat. et Aquce da § ij. Progress of the Case.—November 20th.—At the apex, the cardiac sounds continue exceedingly indistinct and muffled. At the base, immediately above the nipple, there is heard with each cardiac sound an exceedingly soft blowing noise, equal in intensity and duration; it extends over a considerable space, being heard but very feebly under the right nipple. Immediately under the centre of both clavicles, there is a prolonged blowing noise, occupying the period of both sounds. Pulse 72, full and somewhat jerking; palpitations are occasionally urgent; respi- rations 36, labored. Ordered twelve leeches to be applied over the prcecordia, and subsequently warm fomentations. 21st.—The leech bites bled well. There is great * Reported by Messrs. Geo. Robertson and R. P. Ritchie, Clinical Clerks. 36 502 DISEASES OF THE CIRCULATORY SYSTEM. heaving and expansive motion of the whole praecordia; at the apex, murmurs are indistinct—at the base a double blowing murmur, most clear over the head of the sternum. There is no friction audible—no pain, and the palpitations are not increased. Pulse 80, slightly jerking, but weak. She cannot sit up from tendency to faint ; is depressed and exhausted in her aspect. Urine scanty; still contains no chlorides. Ordered three ounces of wine with beef-tea; to be kept perfectly quiet. 22d.—The skin is covered with moisture; respirations 46 ; pulse 84; still jerking and weak. The apex beats exactly under the fifth rib, a little to the inside of the nipple. At the base there is now a loud creaking which is.double, and very loud at the martnn of the sternum. Transverse dulness 3^ inches. Ordered to discontinue the saline mix- ture. In the evening loud friction was audible at the apex as well as at the base, and the apex beat had fallen about two lines below and to the inner side. 23d.—Pulse 72 of same character; respirations 35. At the base" of the cardiac organ, instead of the double friction heard yesterday, there is now a single continuous creaking. The same sound is audible at the apex. 24th.—Pulse 80, still slightly jerking, but soft; respi- rations 36 ; apex as yesterday. There is a continuous churning friction at base; at the apex it is heard, but less loud and continuous. R. Spir. ^Ether. Nitrici 3 iij; Tinct. Colchici 3j; Aquce §vss; M. One ounce thrice a-day. Also R Pulv. Opii gr. iij; Extract. Catechu gr. xv.; Confect. Rosar. q. s. ut fiat massa in pilulas sex dividenda ; one to be taken every sixth hour. 25th.—The same friction murmur; pulse 80; respi- rations 36; urine is hyperlithic; and still contains no chlorides. 26lh.—Pulse 82, slightly jerking, more compressible; respirations 32 ; skin dry and hot; tongue moist; has no appetite; urine the same in character; the friction is less churning and con tinuous, and occurs more with the first sound. 28th.—At the visit to-day, dulness is detected in the left scapular region near the inferior angle, over a space the size of the hand* with crepitation, and pealing vocal resonance. Friction in cardiac region is now diminishing in intensity and duration. Ordered three addUional ounces of wine. (From this day commenced an intercurrent attack of pneumonia, affecting the left lung, ter- minating in seven days.) Besides dulness, crepitation, and increased vocal resonance, there were on the fourth and fifth days a friction murmur at the base of the left lung. The chlorides began to reappear in the urine on the fourth day. A blister was applied (3 by 4) to the right side anteriorly on the 29th, and of the same size to the left lateral region on Dec. 2d. Dec. 2d.—On percussion the transverse cardiac dulness is 3\ inches; the apex beats feebly between the fifth and sixth ribs. At the base, one long rough prolonged sound is heard, and at the level of the nipple this is plainly connected with a second of a friction character. Over the centre of the sternum, on a level with the nipple, this hoarse blowing (or friction ?) is loudest, and is still audible at the right side of the sternum within 1\ inch of the right nipple. Pulse 96, still jerking and soft. Dee. 6th.—Considerable dulness is detected to-day on the right side from the inferior angle of scapula to the base. Respiration is almost inaudible, and is faintly bronchial. Over area of dulness a little fine crepitation may also be detected on inspiration, and vocal resonance is increased. Pulse 126, soft, jerking; respirations 52; great dyspnoea, (From this attack of pneumonia on the right side, the patient began to recover on the seventh day. Throughout the whole course of it, the chlorides in the urine were abun- dant ; there was little cough or sputum.) Dec. 12th.—The cardiac friction murmur has totally disappeared from the apex. At the base a blowing murmur is now heard with the second sound, the first being free from murmur. 26th.—This moming, about 9.30, the patient having assumed the recumbent position for a few minutes, violent palpita- tions came on, and forced her to sit up; she felt as if about to faint, and was so agitated as to be almost unconscious. At 11 a.m., the palpitation had somewhat subsided, but the cardiac action was still very violent, shaking the whole person, and causing severe pain in the chest. Pulse almost continuous, beating about 180 times in a minute, jerking, and incompressible; no difficulty of breathing; no affection of the head; face pale and anxious; patient restless, and occasionally moaning. The urine passed soon after this paroxysm is scanty, of brick color, turbid, clears up on application of heat, but on further heating and being fully acidified, a slight coagulum is obtained. From this paroxysm she recovered towards the evening, under the use of Ammoniated Tincture of Valerian and Sol. Mur. Morphice. 3hst.—Patient now sits up for about two hours every day, and begins to be very hungry. January 1st.—Cardiac signs are the same as at last report; at the apex nothing but a dull impulse is heard; at the base there is still the blowing with the second sound. From this date she gradually increased in strength, moving about in the ward and occasionally taking walks in the PERICARDITIS. 563 town. The pulse 90 to 100 per minute; was easily raised to 100 or 120 by excite- ment. Palpitations also were readily caused by any surprise, lasting for about fifteen minutes and accompanied by a marked soreness along the sternum. On the 15th of February it is reported no change in the cardiac sounds had occurred. The transverse dulness 2J inches; the pulse 96, full and regular, retains its jerking character. Is discharged much relieved on the lVth February. She was re-admitted (under care of Dr. Christison) on the 29th of February, labors ing under an attack of articular rheumatism ; she gradually became convalescent, but continued weak, easily agitated, with painful palpitations and threatening of syncope. The blowing murmur with the second sound at the base continued, but the most careful examination, by inspection, percussion, or auscultation, failed to elicit any other physi- cal sign, the dulness being still 3£ inches across. In this condition she continued in the ward, moving about, and in tolerable health, when on the evening of May 14th she suddenly started up with a cry, and immediately fell back, pale, gasping, and almost pulseless, and expired within three minutes, notwithstanding the sedulous administra- tion of restoratives and stimulants. Sectio Cadaveris.—Thirty-nine hours after death. Thorax.—The pericardium was found universally adherent. The heart was uniformly enlarged, weighing twenty-eight ounces. On passing a stream of water down the aorta, it escaped very freely into the ventricle. On examination the aortic semilunar valves were found thickened and shortened. There were no vegetations on the valves. The auriculo-ventricular orifices, especially on the right side, were a little dilated. The left ventricle was very much dilated, and its walls were fully of the normal thickness. The right ventricle was of normal dimensions. The lungs were congested posteriorly and inferiorly, but were otherwise everywhere natural. The muscular substance of the heart was everywhere of a pale fawn color, soft and easily breaking down under the finger. Abdomen.—The abdominal organs were natural. Microscopic Examination.—The pericardial adhesions were composed of well- formed areolar texture, in firm bands aggregated closely together. The substance of the heart presented all stages of the muscular fatty transformation; the fasciculi in most places being brittle and the transverse stria? obscure, while here and there fatty granules were numerous, displacing more or less of the sarcous substance. Commentary.—This case was carefully observed for nearly a period of six months. On admission it was evident that a pericarditis existed with such distension of the pericardium, that the two diseased surfaces did not rub upon one another, so as to occasion friction murmurs. The pulse was full and jerking, but the exact character of the valvular lesion could not then be determined. There was also dyspnoea, and with a view of diminishing this and other symptoms, twelve leeches were applied, with the effect, however, of rendering her weak and faint. Wine, nutri- ents, and quietude were immediately ordered, and subsequently consti- tuted the treatment. The following day the pericardial distension began to diminish, and a returning friction murmur to appear. As the peri- carditic signs decreased, the evidence of aortic incompetency became more evident, and latterly a prolonged blowing with the second sound at the base was the permanent sign of aortic valvular lesion. She also suffered from two distinct attacks of pneumonia, one on the left, and then subsequently on the right side, during the whole of which time wine with nutrients were assiduously administered, with the effect of conduct- ing her favorably through these formidable complications. All who witnessed the case were satisfied that this woman, during these two pneumonic attacks, in both of which were present all the characteristic symptoms and physical signs of the disease, owed her life to good nour- ishment and stimulants, and that the slightest approach towards an antiphlogistic treatment would have been fatal. It was further observ- able, that at this time the pulse was full and jerking—many would have 564 DISEASES OF THE CIRCULATORY SYSTEM. called it hard—so that she presented what has frequently been described as the symptoms of an exquisite case of pneumonia; in short that very group of symptoms in which writers have advised us to bleed largely. I have myself no doubt, that such cases with aortic disease and dyspnoea were, previous to the days of physical diagnosis, regarded as typical examples of pneumonia, were bled largely, and served to swell the great mortality which, as we shall subsequently show, characterised a former practice. Under an opposite treatment, however, she gradually recovered and became so well (though still laboring under the aortic incompetency with tendency to palpitation), that she insisted on going out. She was so imprudent, however, as again to catch articular rheumatism, and re- entered the Infirmary; the cardiac physical signs, and symptoms, how- ever, remained unchanged. She again recovered, but died suddenly from a fatal syncope. On examination of the body, the correctness of all the facts observed was confirmed, and the nature of the case rendered per- fectly clear. The two layers of the pericardium were everywhere ad- herent ; the aortic valves were thickened and incompetent, explaining the persistence of the valvular murmur and jerking pulse; the left ventricle was hypertrophied, as shown by percussion; and the muscular substance of the heart was very fatty, accounting for the sudden death. Case C*—Acute Pericarditis supervening on Phthisis. History.—Edward Campbell, set. 30, a porter—admitted September 5th, 1856. For twelve years has been of very intemperate habits, unsettled in his occupation, and often insufficiently nourished. About one month ago, he first noticed a short dry cough, attended with little expectoration till a few days ago, when it became rather copious and yellow. Four days ago, the sputum for the first time was tinged with blood; about the same time the stools became frequent and loose, and severe night sweats appeared. He has been subject for some time to shiverings, but cannot re- member any special rigors ushering in the present attack. Symptoms on Admission.—There is a marked dulness on percussion at the apex of left lung, and laterally in the auxiliary region. There is also crack-pot resonance over the left front, from the first to the fourth intercostal space. On auscultation, there are coarse moist rales, during inspiration and expiration, over the whole left lung, anteriorly, laterally, and posteriorly, with increase of vocal resonance, amounting to bronchophony superiorly. Over the lower third of the left lateral region, there is friction with inspi- ration. The right lung gives the normal results on auscultation and percussion. The sputum is copious, frothy, and streaked with blood; considerable dyspnoea; the cardiac organ is healthy; the pulse is 112, rather incompressible; the appetite bad; the bowels arg regular; the skin hot; the face of a purplish hue; the patient is emaciated, weak, and lies on his back; does not sleep well; there is great tremulousness of the limbs; the urine is not coagulable, and it contains abundant chlorides; sp. gr. 1020. Progress of the Case.—September 5th-21st.—Has been treated with small doses of antimony, and a blister two inches square over left mammary region. The strength has been supported by nutritious diet and wine, or occasionally gin. On the 11th, the sputum was carefully examined, and yellow elastic tissue was discovered under the microscope. The physical signs on the left side are very slightly altered; the rales are less numerous; there is more bronchial breathing. At the right apex there is now dulness, harsh respiration, and occasional crepitation at close of the inspiratory murmur. The fever, though still great, has considerably abated. Pulse generally 120, soft. From Sep. 21st to 30th, the pulmonary phenomena were little altered, although they were subject to remissions, but the diarrhoea, which the patient had before only slightly experienced, became very troublesome. Oct. 1st.—To-day a distinct double friction murmur is audible all over the cardiac region, soft at the base, more coarse and loud * Reported by Dr. Thorbura, Resident Physician, and H. N M'Laurin, Clinical Clerk PERICARDITIS. 565 towards the apex. The cardiac dulness on percussion is extended—externally it cannot be limited, but internally it reaches to the centre of sternum. No fremitus; pulse 128, feeble, intermittent, and compressible; respirations 36 per minute; voice hoarse ; cough painful; sputum purulent; patient weak, but feels no pain anywhere, and expresses himself as being so well, that he is even anxious to go out and see a friend. Has no appetite; the diarrhoea continues. Oct. 2d to 9th.—The pericardial friction continues distinct. There is also pleural friction murmur on the left lateral region more distinct and extensive than on admission ; the right side is dull at the apex, with moist rales during inspiration; to-day there are friction sounds during expiration at the right base. Oct. 9lh to 11th.—The auscultatory phenomena are unaltered. The moist rales in lung are more coarse and bubbling: dyspnoea is intense ; respiration 60 per minute ; the face is livid; the pulse more and more weak, becoming imperceptible. Oct. 11th.—Died this morning. Sectio Cadaveris. Fifty-one hours after a^ath. The body was emaciated. Thorax.—The left lung was infiltrated throughout with grey tubercle ; at the apex there was great condensation around three or four cavities containing pus, the largest being the size of a hen's egg. Numerous smaller cavities existed throughout the upper lobe, which, with the cut bronchi, poured out abundant pus on the texture being squeezed. The right lung was also infiltrated with grey tubercle throughout the upper lobe ; at the apex there were two cavities the size of hazel nuts. Its inferior lobe was thinly scattered with the same tubercle, and was greatly engorged with blood and serum. Universal adhesions on both sides. Both layers of the pericardium were covered with yillous lymph, generally about one-eighth of an inch in thickness. Between them were about two ounces of serum. The valves and substance of heart were healthy. Abdomen.—The abdominal organs were healthy. Microscopic Examination.—The structure of the villous lymph in this case was very carefully examined, and Fig. 156, p. 1*75, is a representation of the structure. The villi varied greatly in length and size, and could be perceived by the naked eye. Individually they were of pulpy consistence, consisted of a delicate membrane, covered in many places by layers of pavement epithelium (Fig. 156, b). Their substance con- sisted of an aggregation of fibre cells in all stages of development, several of them were floating loose in the field of the microscope (Fig. 156, c). On the addition of the acetic acid the whole became very transparent, showing the mere outline of the villi, with fusiform nuclei imbedded in them. Here and there they contained transparent spaces or vacuoles, having in some transverse markings or folds externally (Fig. 156, a a). The heart was subsequently carefully injected by Professor Goodsir, and portions of it may now be seen in the University Museum, with the layer of lymph nearest the muscle containing a rich plexus of vessels filled with colored size. Commentary.—On the admission of this man (September 5), he was laboring under intense fever. He had cough and expectoration tinged with blood; dyspnoea; livid face; hot pungent skin; pulse 112, firm; dulness, with cracked-pot sound on percussion over left chest anteriorly ; and coarse moist rales during inspiration and expiration. These w#re the symptoms of acute pneumonia in its suppurative stage. On the other hand, the disease was described to have come on a month before with dry cough ; there was no distinct rigor ushering in the attack ; and the chlorides in the urine were abundant. Hence it might be a ease of acute tuberculosis. His general aspect taught us nothing, as, without being robust, he was by no means emaciated. He was treated with gentle salines, in order to moderate the excessive fever; whilst wine, gin, and nutrients were liberally administered to support his strength. This treatment succeeded in somewhat diminishing the fever. On the 6th day after his admission, I carefully examined the sputum with the microscope, and found it to contain abundant fragments of lung tissue, mingled with numerous pus and a few blood corpuscles. This fact first demonstrated the phthisical character of the disease. Subsequently the 566 DISEASES OF THE CIRCULATORY SYSTEM. pneumonic symptoms disappeared; dulness with moist rales became limited to the apices of both lungs, and the thoracic physical signs were only examined from time to time. At the visit of the 1st of October a double friction murmur was discovered to exist all over the cardiac region so distinct as at once to satisfy me that pericarditis was already fully established. It was unaccompanied by pain, palpitation, or any local functional symptom whatever, so that, without the physical sign of fric- tion, attention would never have been directed to it. Indeed about this period, there had been a remission in the febrile symptoms, there was less cough, and he felt so much better that great difficulty was experienced in making him keep his bed, and even retaining him in the house. The phthisical symptoms, however, continued, the diarrhoea became colliquative, exhaustion came on, and he sunk, without having exhibited one symptom of heart complaint in addition to the physical signs. On examining the body, besides the pulmonary lesion, the heart presented a shaggy layer of lymph covering the whole of both pericardial surfaces. These were already vascular, while their surfaces were covered with epithelium, and they must have been actively engaged in absorbing the serum which separated them, which was small in amount. Here, then, we have a remarkable example of a true acute inflammation of a serous surface coming on under our eyes, which was detected by physical signs alone, and was unaccompanied by any functional symptoms whatever. The only treatment indicated in this case was to support the general strength. As there were no local symptoms, topical remedies were evi- dently unnecessary. In this case, also, we remark an exception to the general laws sup- pcsed to govern exudations, viz., that in a phthisical person, while tu- bercle was thrown into the lungs, an inflammatory exudation was thrown out in the pericardium (See Case LIV. p. 472). Here, however, it was observable that when the pericarditis appeared, his general health had temporarily improved, and he was taking generous diet, a circumstance which may serve to account for the altered constitution of the exuded matter. It must be obvious however, from this, as well as from many other observations previously made, that a true inflammation has no necessary connection with robust constitutions, and that it may come on at the close of the most exhausting maladies. Case CI.*—Ascites—Anasarca—Adherent Pericardium with Fatty Atro- phied Heart—Congested Liver. History.—John Young, aet. 19, a farm servant—admitted April 16th, 1855. Kine months ago he felt pains in the right hypochondrium, and shortly afterwards his abdo- men began to swell. Under medical treatment the swelling subsided, returning when medicines were discontinued, and again subsiding under medical treatment. It hr.s increased a third time, and has induced him to apply for admission. Symptoms on Admission.—He is a stout person, with a protuberant abdomen, no oedema of integument, and very slight yellow tint of the sclerotic. He says there has been swelling of the legs. Tongue moist, and a little coated; appetite good; no dys- phagia nor vomiting. The area of hepatic dulness cannot be determined, owing to the dulness of percussion over the abdomen. On percussion, the distension of the abdomen is seen to be owing to an accumulation of fluid which gravitates to the dependent por- tions. Bowels are regular. Cardiac sounds normal. Area of cardiac dulness is not * Reported by Mr. Robert Byers, Clinical Clerk. PERICARDITIS. 567 stated. Pulse 80, of good strength. On auscultation, sibilant rales are heard all over his chest. He expectorates a good deal of tough frothy mucus. Complains of dyspnoea and cough, especially after meals. Urine scanty (only 12 ounces during the last 24 hours), of natural color, with exceedingly slight trace of albumen. Is ordered a squill and digitalis pill thrice a day. Progress of the Case.—April 19th.—Urine not increasing. Is ordered to apply over his abdomen, spongio-piline soaked in an infusion of digitalis, four times stronger than usual. 25th.—Coughs less, and expectoration is more easy, but urine is not in- creased. A papular eruption has appeared over abdomen from the action of the spongio- piline. 29th.—Has had frequent watery evacuations without griping, and with only slight nausea under the action of elaterium, in the dose of one-sixth and one-fourth of a grain. May 2d.—The spongio-piline was ordered to be removed, as it appears to cause irritation of the integument. 3d.—The cardiac sounds are healthy at apex and base. The abdomen is less tense. The upper border of the area of hepatic dulness is not higher than usual. The lower cannot be determined. The urine is not coagula- ble. 9th.—Has felt more comfortable; the ascites appear slowly increasing. Is ordered half a drachm of compound jalap powder. 11th.—Has felt relieved as usual after pur- gation ; the urine is slightly increased. The feet, legs, thighs, and scrotum, are now oedematous. Habeat Potass. Bitart. 3j ter indies. 13th.—The general anasarca is increasing. Dyspnoea is greater. Urine quite free from albumen. Pulse 63, irregular and weak. Bowels costive. 18th.—Bowels have been kept freely open by the admin- istration of purgatives, chiefly of Extract. Elater., in doses of one-sixth and one-fourth of a grain. Anasarca is not quite so great, and micturition is more easy, notwithstanding the oedematous condition of penis and scrotum. To continue the doses of Bitart. Po- tassa. 21st.—Not so well to-day; feels uneasy in horizontal position; is to get a special pillow for the support of his shoulders and head. Pulse 88, weak and intermittent. 24th.—Pulse 84, weak and irregular; urine 24 ounces in 24 hours; sp. gr. 1028 ; con- tains no albumen. The abdomen is becoming evidently by degrees more and more dis- tended. 25th.—Feels much the same as yesterday; cannot lie down in horizontal posi- tion. Urine 27 ounces, not in the least coagulable. 28th.—Urine continues to range from 20 to 28 ounces per diem ; sp. gr. 1021; no traces of albumen. Feet and limbs enormously swollen. 31st.—Urine diminished in amount; cough is pretty severe. Orthopnoea continues; pulse 94, weak and intermittent. Patient is becoming exhausted, does not even take the food for which he has an appetite, from the distressing sensation of the tenseness of his abdomen. R Spir. jElher. Sulph.: Ammonia; sesquicarb. aa | ss; Aquae, § vj ; one ounce every th'.rd hour. June 3d.—Died to-day. Sectio Cadaveris.—Fifty-six hours after death. Body anasarcous. Face swollen and oedematous; some hemorrhage from the nose. Limbs oedematous; abdomen protuberant and fluctuating ; great cadaveric liver. Thorax.—The right pleura contained nearly two pints of clear serum; the left one pint. The lower lobe of the right lung was compressed and non-crepitant, and the margin of the other lobes emphysematous; otherwise both lungs natural. The pericar- dium was found to be firmly adherent over the whole surface. It was much thickened, , varying from two lines to two and a half, and it was of fibrous or almost cartilaginous consistence. The heart itself was about the normal size, but its walls, particularly those of the left ventricle, were rather thinner than natural, being less than two lines at the apex. The valves and endocardium were healthy; the muscular tissue was of a pale fawn color. Abdomen.—Contained three gallons of clear serum. Liver weighed 3 lb. and 2 oz. Its hepatic vessels were congested, so that the organ presents on section a nutmeg ap- pearance. The spleen soft, weighed 6£ oz.; but was healthy. The two kidneys weighed each 10^ oz.; and were quite healthy. The whole alimentary canal was carefully ex- amined, but with the exception of congestion of the mucous, membrane in the lower two- thirds of the rectum, was found to be quite healthy. The large arteries and veins of the neck, chest, abdomen, and pelvis, were also minutely examined, and found healthy. Microscopic Examination.—The striae in many of the cardiac muscular fibres were indistinct, and numerous minute oil globules were visible within the sarcolemma. The hepatic cells contained somewhat more biliary and fatty matter than usual. But in almost all of them the nuclei could be seen. The renal structure was normal. Commentary.—The history and symptoms of this man induced me to consider his disease as essentially hepatic. According to his account 568 DISEASES OF THE CIRCULATORY SYSTEM. it commenced with ascites nine months before admission, and was fol- lowed by oedema of the legs and general anasarca. On taking charge of the case in May, however, I could not detect any alteration in the size of the liver, or any uneasiness in the right hypochondrium. The heart was carefully examined and found to be healthy, and at no time had he ever complained of that organ. The lungs presented evidence of slight bronchitis, which could never be supposed to have occasioned the dropsy. The urine when scanty contained a slight trace of albumen, which after- wards disappeared. At no time did the case resemble one of Bright's disease, and the kidneys after death were quite healthy. The rapidly- advancing dropsy was the source of danger in this case. As diuretics had no effect, hydragogue cathartics were had recourse to, and although these produced temporary relief, the anasarca went on steadily increasing, and he died. On examining the body, the liver was found to be simply congested, while its structure had undergone little alteration; the peri- cardium was universally adherent, and somewhat thickened; the lungs collapsed posteriorly, with slight emphysema anteriorly. It seems to me that the congested liver and the chief pulmonary lesions were the results rather than the causes of the anasarca, and that the true origin of the disease must be referred to the cardiac lesion. During life, it is true, there were no symptoms or physical signs to indicate that the heart was diseased. But it became apparent after death that he must have had an extensive pericarditis, and we have previously seen that such may occur without any symptoms at all. This, as in the case of Douglas, led to fatty degeneration of the organ, with atrophy, however, instead of enlargement; and the result was that, instead of dying suddenly as in her case, such slow languor of the circulation was occasioned, as to pro- duce the venous congestion in the liver and lungs, which in its turn occasioned the anasarca. In most cases where enlargement of the heart follows adherent pericardium, I have noticed the existence of valvular disease. In the present case the valves were healthy, and, instead of hypertrophy, there was atrophy. Case CI I.*—Rheumatic Pericarditis. History.—Jane Beaton, set. 13, a thin, weak girl—admitted November 30th, 1853. She states that two years ago she was confined to bed for a month with acute rheuma- tism, some time after which, she cannot say precisely when, she observed that her heart was wont to beat very quickly. The impulse also was distinctly seen by her on undressing before going to bed. She had never suffered before from any cardiac unea- siness, pain, or dyspnoea, and asserts that she was able to run about as well as the other children at school, until the commencement of the present illness. Three weeks ago, after no unusual exposure to cold, so far as she was aware, she felt weak, lost her ap- petite, and went to bed early. Next day she could not move in consequence of pain in both hip joints, and in two days the knees, wrists, elbows, and shoulders were also affected. The knees were much swollen, but not red. In eight days the pains abated, and have not since returned. Since then she has been subject to cough, with a white frothy expectoration, but has no pain in the chest, dyspnoea, or palpitation. Symptoms on Admission.—The cardiac impulse is seen and felt in the third, fourth, and fifth intercostal spaces, so low as one and three-fourths of an inch below, and to the outside of the nipple. It is strong, but unaccompanied with fremitus. Per- * Reported by Dr. David Christison, Resident Physician, and Mr. James Walker, Clinical Clerk. PERICARDITIS. 569 cussion causes slight pain. Cardiac dulness was much increased, extending to the right side of sternum, but its exact limits were not determined. All over the cardiac region there was a double friction murmur, appearing close to the ear, and of a fine grating character, but very distinct. Over the manubrium of the sternum is a single blowing murmur, apparently with the first sound. The second sound cannot be heard. Pulse 136, regular, of good strength and somewhat jerking. The chest ex- pands equally on both sides; percussion normal. Respiration harsh and sibilant over right pulmonary apex, over left apex normal. Posteriorly respiratory sounds healthy. She has slight cough, with trifling mucous expectoration. Does not com- plain of dyspnoea, but the breathing is evidently somewhat accelerated. Tongue clean. Appetite somewhat impaired; slight thirst. Bowels regular. No headache; does not sleep well, but no startings at night. Face flushed ; no anxiety of counte- nance ; skin hot and dry; often sweats at night; no oedema of limbs. Other functions normal. Eight leeches to be applied to the precordial region, and a sixth of a grain of Tartrate of Antimony to be given in solution every third hour. Progress op the Case.—December 1st.—Pulse more soft. To discontinue the antimony. R Calomel gr. xxiv; Pulv. Jacobi gr. xxiv; Pulv. Opii gr. iii. M. et divide in chartulas xij. One to be taken every four hours. Dec. 3d.—Friction mur- murs much diminished. Cardiac dulness apparently increased. Urine loaded with lithates. Cough continues. R Sp. yEther. Nit. 3 iij ; Pot. Acet. 3 ij ; Mist. Scillce § vss. M. A table-spoonful to be taken every four hours. Dec. 4th.—Careful examination determined that the cardiac dulness measures five inches transversely, commencing half an inch outside the left nipple, and extending across the sternum to an inch and a half from the right nipple. Friction is now only audible over the margin of dulness on the right side. A soft blowing murmur is audible, synchronous with the impulse over a space of two inches in diameter below the nipple. At the base a harsher blowing is hetird, which alternates with the soft murmur at the apex. It is propagated in the direction of the large vessels, and is very audible under the centre of the right clavicle. Pulse 120, soft, and slightly jerking. No pain or dyspnoea. Gums not affected by the mercurial powders, but complains of tormina and slight diarrhoea. Discontinue the powders, and apply a blister (3 by 4) over the ster- num. Dec. 12th.—Dulness somewhat diminished. Double friction is again very loud over the base of the heart. Dec. 15th.—Dulness much decreased; friction has disap- peared. Dec. 19th.—Dulness now only measures three inches transversely across. Dec. 28th.—Has been doing well, and taking her food regularly. The cough and ex- pectoration have nearly disappeared, and the harshness of breathing on the right side has much diminished. Last night was seized, without apparent cause, with violent palpitation, a sense of suffocation, and coldness of the body, which continued for an hour. Brandy and sulphuric ether were given, and hot bottles applied to the feet. To-day she is tranquil as usual. Impulse is undulating between fourth and sixth ribs. The blowing at the apex is more harsh and prolonged. Above the nipple, on a level with the margin of sternum, there is a superficial blowing, occupying the period of both sounds. It is no longer audible under the clavicle. No retraction of the intercostal space over the undulation visible between the fourth and sixth ribs. January 14th.—Since last report, the attacks of palpitation and dyspnoea have recurred occasionally at night, apparently excited by any unusual circumstance. Puerile respiration still continues on the right side, but all pulmonary disorder other- wise has ceased. There is now heard, both at the apex and at the base, one loud blowing murmur, synchronous with the impulse, occupying the period of both sounds. That at the base is harder and more clanging in character than that at the apex, and ceases suddenly on carrying the stethoscope to the articulations of the third and fourth right ribs with the sternum. Pulse 128, soft. She is easily agitated ; other- wise the same, but says she is better. Wine % ij daily. March 18th.—Since last report, has been greatly better, and has had comparatively few attacks of dyspnoea and palpitation. To-day the impulse is felt distinctly between the sixth and seventh ribs, a little to the outside of a line drawn vertically from the nipple. Over this point a double blowing murmur is heard, that with the second sound being longest and somewhat distant. This blowing increases in intensity and loudness as.the stethoscope is carried obliquely upwards towards the sternum, and reaches its maxi- mum over the articulation of the third left costal cartilage with the sternum. At this point the murmur is prolonged, occupying the period of both sounds. It suddenly ceases as the stethescope approaches the clavicles on both sides, and it is inaudible 570 DISEASES OF THE CIRCULATORY SYSTEM. over the large vessels. Pulse 120, of good strength, jerking; no venous pulse. April. 11th.—Has continued the same, but insists on leaving the Infirmary, and is in conse- quence dismissed. Commentary.—This was an exceedingly interesting case of pericar- ditis and endocarditis, the former of which apparently terminated in ad- hesions, while the latter underwent a variety of organic changes, which were indicated by physical signs, and were carefully recorded in suc- cessive examinations. From these it seems probable that there was gradually developed considerable hypertrophy of the left ventricle, the apex of which descended downwards and outwards, whilst the pulse be- came more and more jerking. The aortic orifice was apparently con- stricted ; and it is curious to observe, that whilst the murmur at the base at first was propagated upwards in the course of the large vessels, it subsequently was propagated downwards towards the apex, and ceased abruptly above at the margin of a certain area. The kind of organic lesion which gradually forming ultimately produced this result, it is use- less speculating about, although it must be evident that the aorta itself above the valves could not have been implicated. At one time it ap- peared to me probable that the pulmonary valves were affected, but a careful consideration of all the circumstances obliges me to negative this supposition. Again, the pressure of the pericardial exudation might have produced the murmur at the base. The constant blowing murmur at the apex indicated mitral insufficiency, a lesion which could not have been so intense as the aortic disease, as the murmur was always more soft, and could easily be distinguished from the one at the base. Indeed, it seemed as if this remained almost stationary, whilst the aortic lesion at length became the predominant one. I heard some few weeks after her dismissal that this girl was dead, but under what circumstances could not be ascertained. No doubt after the long observation and successive careful examinations this case underwent, much might have been learnt from a post-mortem examination. The disappointment which medical men too frequently experience in this particular, doubtless constitutes an argument with some in favor of supineness, and must at all times tend to check that habit of accurate observation, which is so essential for working out the difficult problems still unsolved in the diagnosis of cardiac diseases. Pericarditis consists of an exudation into the pericardial sac: the fibrin of which coagulates and attaches itself to the membrane, while the serum is accumulated in the centre. Changes now occur, in con- sequence of which the solid portion, or layer of lymph as it is called, assumes a villous structure and becomes vascular, whereby, in the majority of cases, the fluid is absorbed, and the two false membranes unite to form an adherent pericardium. These changes are described and figured, pp. 174, 175. (Figs. 155, 156.) This result, however, may be prevented by two circumstances:—1st, The exudation may be small in quantity and limited in extent, when it is transformed into fibrous tissue, becomes covered with a true serous membrane, and there is no adhesion with the opposite surface. This constitutes the white patches so frequently observed on the heart in examining bodies after death, and they are equally frequent on other serous membranes. 2d, The amount of exudation may be very great, the distension of the pericardial sac extreme, and the transformation into vascular absorbing PERICARDITIS. 571 villi thereby prevented. Under such circumstances, the mass of fluid remains stationary, passes into pus, or even increases, in consequence of dropsical effusion from pressure on the veins, and so called chronic pericarditis, or pericarditis with effusion (hydro-pericardium), is estab- lished. Auscultation and percussion are our guides to a knowledge of peri- Fig. 433. pig_ 434 carditis in the living subject. With their aid the physician, if called in at the commencement, can trace the progress of the disease through the stages of commencing exudation with friction, gradual pvriform enlargement with or without friction, absorption and disappearance of the serum with returning friction, and final adhesion of the two surfaces. This was accurately done in Cases XCIX. and CI. An l-S' tl^' ^aCC4 Pericardium with small amount of fluid.—(Sibson ) -(Sibson) Pericardium, of a pyriform shape, as an ordinary pericarditis. 572 DISEASES OF THE CIRCULATORY SYSTEM. adherent pericardium, or a limited exudation confined to the posterior sur- face of the heart, is detectable by means of physical signs with extreme rarity. It is admitted that occasionally a pericardial may closely resem- ble a valvular murmur, but then the former is superficial, often intensified by pressure of the stethoscope, is not permanent, and is liable to be affected by posture, and by the greater or less energy of the cardiac contractions. As regards percussion, it is necessary to remember that when the amount of fluid is small, say from two to four ounces, the peri- cardial sac is not distended, but remains flaccid. The fluid gravitates towards the lower end, and produces the appearance represented in Fig. 433. In case of acute general peri- carditis, such as Cases XCVII. and C, the amount of fluid may reach from ten to twenty ounces, when the pericardium is distended, becomes pyriform with the base downwards, as represented Fig. 434. In such cases it may be determined by percussion, to extend upwards to the top of the sternum, and downwards to below the xiphoid cartilage. It may pass to the right of the sternum on one side, and left of the nipple on the other, more or less displacing the lungs, es- pecially pressing backwards on the left one. In chronic pericarditis or hydro-pericardium, more than three pints of fluid have been found in the sac, in -which case the pyramidal form of acute pericarditis is lost, and it becomes globular, as in Fig. 435. In such cases it encroaches so far on the left lung as to push it entirely back- wards. The liver and stomach are at the same time displaced down- wards to a great extent, by the de- Fis- 435- scent of the central tendon of the diaphragm. Hence the epigastric prominence, and the pain on pres- sure in the epigastrium, sometimes observed in cases of pericarditis. While the increasing effusion into the pericardium displaces the lungs, liver, and stomach, it also causes, especially in the young, prominence of the lower sternum and adjoining left costal cartilages, and widening of the left intercostal spaces. If very extensive, it presses backwards and upwards on the bifurcation of the trachea, causing extreme dyspnoea. In such cases relief is experienced by sitting up and leaning forward in bed, when the pressure on the trachea is removed by the gravitation of the fluid downwards . and forwards.—(Sibson.) Pressure on the oeso- phagus may also occasion more or less dysphagia. Fig. 435. Excessive distention of pericardium, as in chronic pericarditis or hydro- pericardium.—(Sibson.) PERICARDITIS. 573 Functional symptoms, however they may induce us to suspect, can never alone positively enable us to affirm the existence of pericarditis. They are very variable in different cases, and appear to me to be de- pendent more on the general susceptibility of the nervous system, than on anything else. Moreover, we have seen that the symptoms of local pain, dyspnoea, and so,on, are often absent. In the case of Campbell (Case C.), while the friction murmur told its tale with the greatest clearness, he denied that anything was wrong with his heart whatever, and yet after death the two pericardial surfaces were found covered with soft shaggy lymph. In Case CI., where after death there was adherent peri- cardium leading to general anasarca, the man could not remember that he ever was affected in any way with cardiac disorder. (See also Case XC VIII.) This important fact has been noticed by many physicians— thus " acute pericarditis is often so latent as to be discoverable only by physical signs."—[Stokes) " The disease may be absolutely latent from first to last. I have known patients with several ounces of fluid and exudation matter in the pericardium, grow irritated when inquiries were made about symptoms connected with the heart."—(Walshe.) But the cases of Douglas and Young, which have been recorded, must satisfy us that pericarditis is a most serious complaint. The adhesions which form often more or less embarrass the action of the heart, and, above all, impede its normal nutrition; in the one case they caused general dropsy, and in the other fatty degeneration of the texture of the heart. Much has been written as to the complications of pericarditis. Its association with acute rheumatism is so common, that some have classi- fied cases into rheumatic and non-rheumatic (Ormerod, Markham). The causes of this association are as yet unknown. Dr. Taylor further sought to establish a relation between pericarditis and Bright's disease. Thus, out of 38 of hi3 cases, 20 occurred in the progress of acute rheu- matism, and ten were complicated with renal disease. It so happens, that in none of my cases of pericarditis has there been a complication with Bright's disease; and yet this last lesion is so common in Edin- burgh, that it is scarcely conceivable, if it were really a cause of the former, that it should have escaped my notice. Dr. Christison also says, in his work on " Granular Degeneration of the Kidneys " (p. 94), that " pericarditis is seldom seen among the sequelae." We cannot, therefore, be too cautious in reasoning as to the causes and treatment of pericar- ditis from the supposed conditions of the blood with which it is thought to be associated. Complications with pleurisy, pneumonia, and pul- monary emphysema, are much to be dreaded, especially as regards the ultimate effects on the heart itself, although they may not prove imme- diately fatal. (See also Cases CVII., CVIIL, and CX) The treatment, like that of all other forms of acute inflammation up to a recent period, was at first antiphlogistic, but, for the reasons previously given (p. 313), this is no longer the rule. Case XCVII. demonstrates how, in a tolerably healthy person, the disease passes rapidly through its natural progress. But should there be depression of the vital powers, stimulants and nutrients are demanded, as in Case XCIX. If there be local pain, the application of a few leeches, or, 574 DISEASES OF THE CIRCULATORY SYSTEM. what is often better, of warm fomentations or a hot poultice, tends to relieve it. Quietude of body and mind is essential to the treatment. In young persons especially, unnecessary physical examination should be carefully avoided. If the principle of practice formerly put forth be correct (p. 313), viz., that a true inflammation cannot be cut short, and that the only end of judicious medical practice is to conduct it to a favorable termination, we should expect its truth to be manifested in such a disease as pericarditis. Now this, I think, we do see. Contrast the treatment of Hope with that of Stokes, and what a difference is observable ! The former energetic in lowering remedies, the latter cautious and constantly warning us not to proceed too far. Though he recommends blood-letting, it can only be practised with his consent, at a time, to j n extent, and under circumstances when obviously it is likely to do no harm. On the other hand, he points out how, in some circum- stances, even a vigorous action of the heart, a jerking pulse, and an in- creased action of the carotids, do not necessarily contra-indicate wine; " * and remarks, " that the omission of that active antiphlogistic treatment, still so often employed in the first stages of inflammation, might be of no great detriment to the patient." f For my own part, I am satisfied that there are no circumstances in which an antiphlogistic practice can diminish the progress of the disease, whilst in the vast majority of cases it does positive harm, by checking the vital force so necessary for en- abling the patient to struggle through his malady. It has been supposed that the action of mercury has an especial tendency to favor absorption in cases of pericarditis, not only of the serum, but of the organized lymph itself. I have now given it in many cases, two of which are recorded at length (Cases XCVIII. and CIL), but could never satisfy myself that it had the slightest influence in forwarding or modifying then atural changes which occur. The best evidence on this subject, however, is to be derived from a careful analysis of forty cases of acute rheumatic pericarditis, by the late Dr. John Taylor, in which mercurial ptyalism was produced with the following results :—1st, Ptyalism was not followed by any abate- ment of the pericarditis in twelve cases. 2d, In one case ptyalism was followed by speedy relief. 3d, In two cases ptyalism was followed by a diminution, and then gradual cessation of pericardial murmur. 4th, In one case pericardial murmur had been diminishing for some days before, and it ceased soon after ptyalism was produced. 5th, In one case pericarditis and pneumonia both increased in extent and intensity after ptyalism. 6th, In four case pneumonia supervened after the establishment of, and therefore was not prevented by, ptyalism. Was it caused by it ? 7th, In three cases endocarditis supervened after ptyalism. 8th, In six cases ptyalism was followed by pericarditis. 9th, In one case ptyalism could not be produced, and yet the pericar- ditis went on favorably. 10th, in two cases ptyalism was followed by extensive pleuritis. 11th, In one case ptyalism was followed by erysipelas and inflammation of the larynx. 12th, In two cases rheu- * Stokes on Diseases of the Heart, etc., 1st edit. p. 89. f Ibid., p. 15. VALVULAR DISEASES OF THE HEART. 575 matism continued long after ptyalism was produced.* Thus out of the forty cases only four can be said to have become better after the mer- curial action on the system was established, and in these there can be little doubt that it was purely a matter of coincidence. Indeed, I have often observed in hospital cases, that when mercury has been said to be most successful, its physiological action has been established just about the time when, during the natural progress of the disease, the friction or blowing murmur may be expected to cease. It seems to me impossible to reconcile these positive facts with the strong opinions of some eminent physicians as to the good effects of mercury in pericarditis. " If a person," says Graves, " is seized with very acute pericarditis, how unavailing will be our best-directed efforts, unless they be succeeded by a speedy mercurialization of the system ! " The case of Stambroke (Case XCVII.) is alone a sufficient answer to such a remark, not to mention the researches of Louis, who demonstrated that only one out of six cases was fatal when they were left entirely to nature. Acute pericarditis, therefore, should be treated according to the general principles previously referred to. During the acute febrile symptoms, salines and quietude. If there be much local pain, a few leeches and local warmth. If there be excited action and dyspnoea, ether and morphia, and as early as possible nutrients and wine to support the vital changes which it is necessary for the exudation to go through, so as to favor absorption. Active purgatives should be avoided, and I am by no means sure that blisters are of any avail. My experience induces me to concur with a remark of Dr. Markham, viz., " that rheumatic peri- carditis is an inflammation attacking rather those of weak than of strong constitution; that it is much more common in the delicate and young than in vigorous persons in the prime or middle periods of life; that the degree of inflammation—that is, the general febrile reaction and the local exudation—is also greater in them than in the strong; and more- over that the disease is more fatal." f VALVULAR DISEASES OF THE HEART. Although morbid anatomists have described a variety of lesions which may cause imperfect action of the valves of the heart, I prefer grouping them together under one head. However they originate, whether from mechanical rupture, from endocarditis, deposits of fibrin, morbid growths, or other cause, they practically amount to the same thing. The disease is imperfect valvular action, and the duty of the physician is to prevent as much as possible the consequences which this is likely to occasion. It is also his duty—while taking every advantage of the laborious efforts which have been made to place the physical diagnosis of those valvular injuries on an exact basis—to remember that perfection is far from having been reached. Careful observations are still required to clear up many doubtful points, and to unravel the * Brit, and For. Med. Review, vol. xxiv. f Markham on Diseases of the Heart, etc., p. 103. 576 DISEASES OF THE CIRCULATORY SYSTEM. difficulties which arise from complication of injuries in the mechanism and vital properties of so important an organ. Hence, notwithstanding the admirable monographs which have been published on this subject, constant research is necessary, not only to confirm what is already known, but to determine with precision points that are doubtful, and conditions as yet scarcely recognizable. " A time may come," says Stokes, " when the science of diagnosis will be carried to such perfection, that we shall unfailingly determine not only the condition of each portion of the heart, but discover the rise and watch the progress of every in- terstitial change in its structure, and every mutation of its vitality."* If so, it can only be done by the careful study and analysis of individual cases. Case CIILf—Rupture of Aortic Valves. History.—Andrew Anderson, set. 32—admitted May 17th, 1859—a soldier, who has been through the campaign in India with Havelock, and was present at the latter part of the siege of Lucknow. On the 16th of June 1858, having been in pursuit of the enemy, and ridden 32 miles on horseback, he experienced on dismounting a giddi- ness in the head. He then went into his tent, and fell on the bed. The doctor of the regiment immediately examined him, and told him he was to leave off active duty. He himself, and, he says, the neighboring bystanders, without putting their ears to his v chest, heard a ioud murmur accompanying the actions of the heart. Since then he has never been on active service. He has been cautioned never to exert himself. He was sent home from India, and arrived at Chatham on the 25th of March, and was dis- missed from the army on the 27th of April last. The noise which he heard at first has gradually become less, and his health otherwise has not been deteriorated, with the exception of vertigo on attempting any unusual exertion. Symptoms on Aomission.—The apex of the heart beats under the junction of left seventh cartilage with the ensiform cartilage. On percussion, the transverse dulness measures 4 inches and one-eighth of an inch, the internal limit being half an inch from the mesial line on the right side. On auscultation over the apex, the first sound is normal, the impulse considerable, but with the second sound there is a loud, wheez- ing, rough murmur. This is audible all over the anterior surface of the chest, but is loudest over the third costal cartilage on the left side, and over a space about the size of a palm of a hand, extending towards the right. The same sound is audible, but very distant, all over the back. Pulse 88, regular, full, and jerking. Other systems normal. He only further complains of dreaming, and occasionally starting in the night, waking suddenly, and breathing hurriedly. The murmur is very loud over the right carotid artery. Did not remain in the hospital. July 4th, 1860.—Says that for the last six weeks he has occasionally felt a sharp burning pain opposite the insertion of the third costal cartilage in the breast bone on the left side. He had also ex- perienced during the winter giddiness, which occasionally returned, especially after a full meal. Ordered a warm poultice to the seat of pain if it be severe. Physical signs the same. Died suddenly in Glasgow, August 1862. Commentary.—There can be no doubt that the accident which hap- pened to this man, and incapacitated him from duty, was a rupture of the aortic valves. The whizzing murmur with the second sound loudest at the base of the heart, the giddiness, jerking pulse, and hypertrophy of the organ, were the proofs of this. We have had two similar cases in the Clinical wards since, one of which was caused by severe cough- ing, and another by the kick of a horse. In such accidents nothing can be done but cautioning the individuals not to exert themselves suddenly or continuously, and to avoid all causes which may excite disease in the lungs. * Op. Cit., p. 342. f Reported by Mr. John Nicholson, Clinical Clerk. VALVULAR DISEASES OF THE HEART. 577 Case CIV.*—Incompetency of Aortic Valves—Dilated Hypertrophy of left Ventricle—Dilatation of Ascending Portion of Aortic Arch—Chronic Arteritis with Aneurismal Pouches. History.—William M'Ritchie, set. 38, fireman on board a Newcastle steamer, entered the clinical ward, complaining of palpitation, dyspnoea, and cough, on the 4th of January 1850. At that time it was ascertained that the cardiac dulness was of unusual extent, and that a blowing murmur existed with the second sound at the base of the heart. He remained in the house under treatment until February 2d, when all the urgent symptoms having left him, he was dismissed. He was re-admitted on the 14th of March, the palpitation, cough, and dyspnoea having returned, together with anasarcous swelling of the abdomen and inferior extremities. Symptoms on Admission.—On percussion, the cardiac dulness measures four inches transversely. The apex beats between the sixth and seventh ribs external to the nipple. The carotid and subclavian arteries beat strongly. A loud and prolonged bellows murmur is heard with the second sound, loudest at the base of the heart, and propagated in the course of the large arteries. First sound is normal in character. Pulse 70, regular, hard, and jerking. Respiration hurried; cough and dyspnoea urgent; inspiration harsh; expiration prolonged; face livid; pain and dizziness in the head; occasionally loss of vision ; disturbed sleep; nausea and anorexia; abdomen considerably swollen from ascites; inferior extremities oedematous; legs cold. Progress of the Case.—During April the symptoms continued with more or less intermission. In May he became liable to attacks of syncope, accompanied with angina and palpitations. In the beginning of June it was observed that the bellows murmur with the second sound assumed a rougher character over the arch of the aorta. He also complained of dysphagia and a pulsation in his throat, which obliged him to keep his head in a particular position. On the 14th he was seized with an unusually severe attack of angina and syncope, which in ten minutes was fatal. The treatment consisted principally in the exhibition of a variety of expectorants and anti- spasmodics, of which a draught containing ten minims of chloroform, and a teaspoon- ful of Tr. Cardam. Co. afforded him most relief. A few leeches were also applied oc- casionally to the cardiac region. Sectio Cadaveris.—Forty hours after death. Thorax.—The pericardium contained three ounces of serous fluid. There was hypertrophy with dilatation of the left ventricle of the heart, in consequence of which the organ weighed 1 lb. 4 oz., and its transverse diameter measured five inches. The mitral valve was healthy. The aortic valves were considerably thickened and curled inwards. Immediately above them the aorta was unusually dilated, the diameter of its calibre being two and a quarter inches. Water poured upon the aortic valves from above passed through the orifice without apparently receiving any impediment. One inch below the origin of the left subclavian there was an aneurismal pouch, the size of a walnut, projecting half an inch from the general outline of the vessel. The arteria innominata, and the origin of the right carotid artery, were also somewhat dilated, and there was an aneurismal dilatation .of the aorta opposite the superior mesenteric artery. The aorta, the coronary, and several of the larger arteries, were roughened internally by atheromatous deposits. The lungs were emphysematous anteriorly, and oedematous at their apices. Head.—Brain pale ; slight subarachnoid effusion; cerebral arteries slightly athe- romatous. Abdomen.—Abdominal organs healthy. Case CV.f—Incompetency of Aortic Valves—Hypertrophy of Left Ventricle and Auricle—Obstruction and Incompetency of Mitral Valve—Pneumonia. History.—Samuel Crawford, get. 42, employed at Chemical Works—admitted June 10th, 1850. He has been subject to palpitation and dyspnoea, after any con- siderable exertion, for four or five years. Last February he had to leave off work on account of these symptoms, which subsided in a fortnight under medical treatment. * Reported by Mr. Hugh M. Balfour, Clinical Clerk. f Reported by Mr. David Christison, Clinical Clerk. 37 578 DISEASES OF THE CIRCULATORY SYSTEM. Three days ago they once more returned. He has noticed, during the last four or five months, swelling of the feet, legs, and abdomen. He never had rheumatism or any other serious complaint. Symptoms on Admission.—The cardiac dulness measures three inches and a quarter transversely. The apex beats between the sixth and seventh ribs, two inches below and to the left of the nipple. The carotid and subclavian arteries beat strongly. Over the apex a bellows murmur is heard with both sounds of the heart. Over the base there is a loud prolonged blowing murmur with the second sound, which is pro- pagated in the course of the large vessels. The first sound heard at the base is un- usually short and muffled. The pulse is regular, strong, and jerking. He has cough, and considerable dyspnoea. Percussion over the loins is resonant, but posteriorly and inferiorly there are fine moist rales. He is liable to giddiness and a feeling of i'aint- ness on sudden exertion. Can only sleep in a half sitting posture, resting somewhat on his left side. Considerable oedema of the lower extremities. Other functions normal. Progress of the Case.—The cough and dyspnoea continued. On the 13th of June the urine became scanty and high colored. On the 17th there was diarrhoea. Moist and dry rales were heard over a considerable portion of chest, and there was much cough and expectoration. On the 26th the urine was again abundant, but there was general fever, cough suppressed, dyspnoea, and expectoration tinged with blood. Pulse 108, full and hard. Crepitant and mucous raies were heard over the lower portion of the right side. On the 28th all oedema of the extremities had disappeared, but there was decided pneumonia on the right side. Low delirium during the night. Died on the morning of the 29th. On the first day § x of blood were drawn from the arm with immediate relief, but it was followed by sleeplessness and agitation at night. He was then ordered § vj of wine daily, and a mixture containing expectorants and diuretics, with tincture of digitalis. Local blood-letting, by means of leeches, was also practised from time to time. The scantiness of the urine and oedema gave way under the use of cream of tartar in 3 j doses three times a-day. "When the pneumonia came on, local blood-letting, by cupping to § xij, and tartrate of antimony internally, were employed, but without success, although the former relieved the dyspnoea. Sectio Cadaveris.—Forty-eight hours after death. Thorax.—The pericardium contained four ounces of straw-colored serum. The heart weighed twenty-three and a half ounces. This increase in size was owing to hypertrophy of the walls of the left ventricle and auricle, and to dilatation of the right ventricle. The aortic valves were fringed with numerous warty vegetations. One of the valves was ruptured, and the ruptured edges were studded over with granules of recent; exudation. In consequence of these lesions, the valves allowed water to rush rapidly through, when poured on them from above. The septal leaf of the mitral valve was perforated in two places by orifices of sufficient size to admit a crow quill. These orifices were surrounded by vegetations, presenting a funnel-shaped prolongation on the internal surface of the valve, through which the orifice passes. There were several other vegetations on the opposite leaf of the valve and fringing its margin. One of the chordae tendineae was broken across at its valvular attach- ment, the ruptured or floating end being thickly covered with fibrinous vegetations. Aorta healthy. The lower, middle, and a portion of upper lobe of right lung dense, hepatized, presenting a reddish-grey color, and yielding sanguineous pus on squeezing the cut surface. Abdomen.—Abdominal organs healthy. Commentary.—Both the cases now detailed exhibit very strongly how the rules formerly mentioned, correctly applied, enable us to de- termine the nature of the cardiac lesion present—for you will remember that, in both, the lesions named at the head of each case were con- fidently stated to exist before the body was examined. In case CIV. " a bellows murmur was heard with the second sound, loudest at the base of the heart, and propagated in the course of the large arteries.' Rule 5 tells us that this indicates aortic insufficiency, and on examina- tion such was found to exist. As the case progressed, however, he com- plained of a pulsatioi in his throat and of dysphagia ; and it is worthy cf remark, that uot only had an incipient aneurism formed in the arch of VALVULAR DISEASES OF THE HEART. 579 the aorta, which explained these symptoms, but that a tendency to the formation of aneurisms existed in other parts of the arterial system. In case CV. the diagnosis, though more complicated, and therefore more difficult, was also determined on by paying attention to the same, rules. " Over the apex a bellows murmur was heard with both sounds of the heart." Now rule 6 tells us that this indicates mitral obstruction with insufficiency, and a description of the lesiou found affecting this valve after death, must convince us that Whilst the vegetations prevented proper closure of the orifice, some of them must also have obstructed the How of blood in its passage from the auricle to the ventricle. But there was also a bellows murmur with the second sound, heard loudest at the base; and this, as in Case CIV., is a sign of aortic insufficiency. A careful determination of the cardiac signs, therefore, and an exact appre- ciation of the facts in the first instance, led us, in accordance with the laws previously generalized, to a correct conclusion as to the nature of this complicated case. No two cases could better convince you of the diagnostic value of physical signs. The treatment in the last case is what I should now consider as far too depletory. On looking back to it after fourteen years' additional experience, it will be observed that it confirms all that I have previously stated as to the inutility of such prac- tice. The hard pulse of the pneumonia which ushered in death, was evidently caused by the aortic disease, in the same manner that a similar complication in the course of pericarditis was attended with the same symptom. (See Case XCIX.) Case CVIft—Incompetency of Mitral Valve. History.—Agnes Murray, aet. 41—admitted June 16th, 1850. About eighteen months ago she first experienced, without any obvious cause, palpitations and pains in the cardiac region, which have continued ever since. They became more violent after exertion, and were accompanied by dyspnoea. Latterly there has been an oedematous swelling of the legs, abdomen, and face. She has had four attacks of haemoptysis, the first occurring eighteen months and the last three months ago. Symptoms on Admission.—The cardiac dulness measures two and a quarter inches across. The apex of the heart beats under the sixth rib, below and a little outside the nipple. Over the apex there is heard a harsh bellows murmur, which diminishes in intensity towards the base and large vessels. Pulse 80, weak. Great dyspnoea and palpitation on exertion, and occasional severe pain in the cardiac region. Resonance of lungs natural. Posteriorly, over right lung, loud sibilant murmurs are heard, both with inspiration and expiration. Expectoration abundant. No anasarca at present, or cerebral symptoms. Progress op the Case.—This woman, under the action of small doses of digitalis and cream of tartar, and the occasional application of a few leeches to the cardiac region, became gradually much better. The palpitations, dyspnoea, and bronchitis dis- appeared. She was dismissed greatly relieved, July 16th. Case CVII.f—Incompetency of Mitral Valve—Pulmonary Hemor- rhage—Hydrothorax. History.—Robert Ross, set. 30, a lath-splitter—admitted June 28th, 1850. For some time past he has occasionally experienced palpitation, and observed now and then slight swelling of the legs. He first became severely ill only seven weeks ago, when he was seized with repeated vomitings, which continued two days. He sub- * Reported by Mr. Edmund S. Wason, Clinical Clerk. t f Reported by Mr. David Christison, Clinical Clerk. 580 DISEASES OF THE CIRCULATORY SYSTEM. sequently caught cold, to which he is very liable, and since then has been laboring under cough, dyspnoea, a feeling of tightness across the upper part of the abdomen, and general weakness. Symptoms on Admission.—Cardiac dulness cannot be distinctly defined. The apex beats feebly between the fifth and sixth ribs, two inches below the nipple. A bellows murmur is heard with the first sound over the apex, but much more dis- tinctly three inches to the right of it, near the sternum. It is almost inaudible over the base. The second sound is normal. Pulse 100, small and soft. Considerable dyspnoea and cough; sputa viscid and tinged with blood. No dulness on percussion over the lungs. Sibilant, mucous, and crepitating rales are heard very generally over the inferior parts of chest, both anteriorly and posteriorly. No increase of vocal resonance. The general surface is slightly jaundiced. On careful percussion of the liver, its inferior border presents a prominence, anteriorly the size of an egg, over the pylorus. Progress of thh Case.—Up to the 3d of July there was occasional vomiting. The inferior extremities became oedematous, and fluid accumulated in the abdomen. On percussion the resonance over the right lung is diminished as high as the scapula; there is a slight increase of the vocal resonance. On the 8th of July the surface generally was anasarcous. From the 10th to the 15th, the dyspnoea greatly increased. He expectorated on various occasions mouthfuls of florid blood. Latterly, he could only lie on the left side. The left side of the chest became completely dull on per- cussion, with absence of respiration. He was now removed from the Infirmary by his friends. Leeches to the epigastrium, with naphtha and anodynes internally, checked the vomiting. The principal object of the treatment, however, was by means of diuretics, to increase the amount of urine, and thereby diminish the anasarca. Pills of lead and opium were also administered to check the haemoptysis. Commentary.—The two last cases contrast very strongly with the two first. In both, the bellows murmur was heard only with the first sound, loud over the apex, diminishing towards the base; and rule 4 tells us that this indicates mitral incompetency. The concomitant symptoms fully bear out this diagnosis. The pulse was weak,—the pul- monary organs were those disturbed, while the cerebral functions were unaffected. In Case CVI. there was bronchitis which diminished under appropriate treatment. In Case CVII. bronchitis also existed, but it was much more general, and mingled with a certain degree of collapse of the lung on the right side. Extravasation of blood into the pulmonary tissue of both lungs had most probably also taken place, as indicated by the haemoptysis; and, latterly, the general dropsy which prevailed affected the thoracic cavities, causing hydrothorax on the left side. The man was evidently in a dying condition when his friends insisted on his removal; and I was rather surprised to hear that he lingered a fortnight before death took place. No examination could be obtained. Case CVIIIft—Mitral Incompetency—Hypertrophy of left Ventricle —Attack of Acute Rheumatism, followed by Aortic Incom- petency. History.—John Conolly, set. 49, a joiner—admitted June 22d, 1850. He has for some years past been subject to pain in, and swelling of, the joints. Eighteen months ago he was suddenly seized with pain in the cardiac region, unaccompanied by dyspnoea, but followed by severe cough. He has been copiously bled, and under- gone a lengthened treatment. Symptoms on Admission.—The cardiac dulness measures 2J inches across. The apex beats in a hollow between the xiphoid cartilage and the cartilage of the seventh left rib. Heart's impulse strong. A bellows murmur can be heard with the first sound, synchronous with the cardiac impulse. It is loudest at the apex, and dimi- nishes in intensity towards the base. Pulse 74, full and strong. No cough, but * Reported by Mr. Charles Murchison, "Clinical Clerk. VALVULAR DISEASES OF THE HEART. 581 considerable dyspnoea on making the slightest exertion. Percussion and auscultation indicate slight pulmonary emphysema anteriorly, but no bronchitis. Slight tinnitus aurium, and dimness of vision occasionally. There is a patch of psoriasis Jigurata, an inch and a half hi diameter, on the right cheek and side of the nose. Progress of the Case.—July 1st, he was attacked with severe articular rheumatism in the hip, knee, and wrist joints, which had entirely disappeared under appropriate treatment on the 9th. On the 14th he had diarrhoea, accompanied by considerable discharge of blood per anum. This continued in smaller quantities from time to time. On the 22d, a careful examination exhibited a change in the cardiac signs. The im- pulse over the apex was more prolonged, with a deep murmur and jog. The bellows murmur synchronous with the impulse was no longer audible, but one can be heard alternating with it at the base—that is, with the second sound. Great pulsation of the carotid, subclavian, and humeral arteries was seen and felt, and a loud puffing murmur, synchronous with their dilatation, could be heard over them. His general health, how- ever, was greatly improved, the local and other symptoms have disappeared ; and he left the house at his own desire, July 24th. At first he took digitalis for six days, with a view of diminishing the cardiac impulse and pain. It was then suspended on account of the nausea and weakness it apparently occasioned. The rheumatic fever and arteritis were combated by salines, diaphoretics, and venesection to the extent of § xij. Afterwards the local pains rapidly yielded to small blisters placed over each affected joint. The diarrhoea and discharge of blood were checked by pills of lead and opium. Commentary.—This man, after frequent attacks of rheumatism, entered the Infirmary laboring under hypertrophy, with incompetency of the mitral valve. At the time there was no bronchitis, but he had previously suffered from severe cough and pulmonary derangement. Whilst in the house, one of the acute rheumatic attacks came on. Many of the joints were swollen and exceedingly painful. This affection was treated by one small general bleeding, tartar emetic internally, and blisters locally. The effect of this attack was to give rise to acute endocarditis, which, instead of affecting the auriculo-ventricular orifice formerly diseased, fixed itself upon the aortic valves. This lesion, however, must have been slight—probably limited to a few small vegetations upon the margins of the valve—because the murmur was soft in character, and the incompetency not of such amount as to occasion either cerebral or other functional symptoms. The pulsation in the large vessels, how- ever, was greatly augmented, and there is every reason to fear, that should the incompetency continue (as is most probable), the aorta and cavity of the left ventricle will both become dilated. Case CIX.*—Mitral Incompetency—Hypertrophy of Left Ventricle— Aortic Incompetency and Obstruction—Anyina. History.—Edward Monro, aet. 41, a painter—admitted June 24,1850. Two year3 ago, without any assignable cause, he was suddenly seized with angina, consisting of severe pain in the middle of the sternum, often running down the left arm, accompanied by violent palpitations. Since then the paroxysms have been increasing both in fre- quency and intensity. Symptoms on Admission.—The cardiac dulness below the nipple measures three and a quarter inches transversely. The apex of the heart cannot be felt to beat at any par- ticular spot. Heart's action is regular. A distinct bellows murmur can be heard ac- companying both the first and second cardiac sounds, which are equally loud at the apex and at the base. Both are heard loudest to the right of sternum, opposite tho second, third, and fourth costal cartilages. A loud blowing murmur is heard over the carotid arteries. Pulse 74, regular. Has a slight cough with expectoration. Lung3 resonant en percussion, and on auscultation the inspiratory murmurs are louder and rougher than natural, and the expiration is slightly prolonged. He has frequently ex- * Reported by Mr. Charles Murchison, Clinical Clerk. 582 DISEASES OF THE CIRCULATORY SYSTEM. pectorated small quantities of dark-colored blood. There is great dyspnoea on makin" the slightest exertion, and he has occasional severe attacks of angina. There is con" siderable dyspepsia. Slight dimness of vision, and muscae volitantes, but otherwise no cerebral symptoms. Progress of the Case.—The attacks of angina returned four or five times a day. They occasioned great agony, profuse perspiration, and increased action of the heart during which the murmurs were heard louder. There was also occasional nausea and tendency to vomit. On the 8th of July he fainted, being unconscious for five minutes. At this time the murmur with the first sound assumed a winning character heard loudest at the apex. There was a double bellows murmur heard distinct from this at the base. July 11th.—There was cough and expectoration. A fine moist rale could be heard over the lower half of left chest, both anteriorly and posteriorly. No dulness on percussion, or increased vocal resonance. July 15th.—He has now only one attack of angina in the day which is also much less severe. The cough and expectoration are diminished. A mucous rale still perceptible in left lung inferiorly. A whimV murmur with the first sound is still heard at the apex, and* a double bellows murmur at the base, propagated in the course of the great vessels. He left the house at his own desire. The attacks of angina were at first treated with anodyne and antispasmodic draughts containing ill v. of chloroform for a dose. Afterwards they were greatly re- lieved by taking carminatives, such as three drops of each of the oils of aniseed and cajeput dropped on sugar. Latterly they greatly diminished after § vj of blood were drawn from the cardiac region by cupping. The bronchitis was treated with anodynes and expectorants. Commentary.—When this man entered the Infirmary it was very difficult to determine at what point the two bellows murmurs were heard loudest. Bepeated and careful examination failed to discover whether one or both were referable to the apex or to the base; and in consequence we could not, according to the rules given, determine whether the disease was aortic, mitral, or both. This was probably owing to the circum- stance of the abnormal murmurs originating in two places, and being at the same time so similar in tone, that the diffusion of sound was pretty equal over the whole cardiac region. But as the case progressed, the murmurs underwent such modifications as left us in no doubt. The murmur with the first sound over the apex assumed a whining tone so that it was easily separated from the double bellows murmur which still remained loud at the base. The former, according to the rules given, must have depended on mitral incompetency; whilst the latter, for the same reason, must have been owing both to incompetency and obstruction of the aortic orifice. The man labored under slight pulmonary, as well as cerebral, symptoms. His chief complaint, however, was the angina, the attacks of which were in him very severe, causing the most excrucia- ting agony and bathing the whole surface with sweat. This, in its turn, seemed to be connected with a state of dyspepsia which existed. When- ever gas accumulated in the stomach, so as to distend that organ and press the heart upwards, the attacks were most severe. The carminatives gave relief by causing discharge of this gas. After local bleeding, aud an improvement in his general health, but more especially in the dyspeptic symptoms, the angina diminished in intensity. The two last cases recorded exhibit how important it is carefully to examine the cardiac signs from time to time as the case progresses, and to watch the modifications they undergo. Where doubt and difficulty prevail, it is only in this way they can be removed. Under such cir- cumstances, never state an opinion at all, but continue to watch until the signs become permanent and unequivocal. This advice you will find to VALVULAR DISEASES OF THE HEART. 583 be even more useful in private than in hospital practice, for reasons which I shall allude to hereafter. But not only are frequent examina- tions useful in clearing up difficult points in diagnosis, they also reveal to the pathologist the changes which take place in the affected parts. Of this the following case affords us an instructive example. Case CX.*__Incompetency of the Aortic Valves with Musical Murmur— Hypertrophy with Dilatation of Left Ventricle—Pneumonia—Pidmon- ary Hemorrhage. History.—William Caird, set. 29, laborer—admitted May 30, 1850. Five months ago he first noticed that he became unusually breathless, and had palpitations after exertion. He continued to work until two months ago, when, being engaged in lifting heavy stones, he was suddenly seized with pain hi the cardiac region, violent cough, and haemoptysis. He entered the Glasgow Infirmary, from which he was discharged, much relieved, in a fortnight. Since then he has been subject to giddiness, dyspnoea, and palpitation, with occasional haemoptysis. Symptoms on Admission.—Cardiac dulness extends three and three quarter inches transversely. The apex beats between the sixth and seventh ribs, three inches below, and a little to the left of the nipple. A bellows murmur is heard with the second sound, loudest at the base, and propagated in the course of the large vessels. The first sound is normal. Pulse 92, strong and regular. He feels a shooting pain in the cardiac region, extending to the epigastrium. There is great dyspnoea, and palpitation on ex- ertion. Slight cough, and fine moist rale in both lungs, heard inferiorly and posteriorly. Occasional giddiness. Progress of the Case.—The pain in the cardiac region and epigastrium was the chief source of complaint during the progress of the case. The dyspnoea and palpitations were from time to time distressing. There was occasional vomiting. On the 12th of July, it was observed that the bellows murmur assumed a whining character, and on the 15th it was distinctly musical, like the chirping of a small bird. On the 17th, the heart's action was tumultuous, and vomiting was very distressing. On the 23d there was considerable haemoptysis, mouthfuls of blood being evacuated. On the 24th, there was dulness on percussion, over the inferior portion of chest, and distinct crepitation could be heard with increased vocal resonance. The cardiac dulness was determined; on careful percussion, to measure five inches transversly. The vomiting and haemop tysis defied all remedies. The pulse was 100, soft. He gradually became weaker. The urine was scanty, and oedema of the legs appeared. Latterly there was muttering delirium at night. Died on the 29th. At first he experienced relief from the cardiac and epigastric pains, after small local bleedings by means of leeches and cupping. Blisters were also applied. All kinds of remedies were tried to check the vomiting, but with little effect. Antispasmodics were employed to relieve the dyspnoea; and latterly as the pulse became weak, wine and stimulants were freely administered. Seetio Cadaveris.—Thirty hours after death. Thorax.—Heart much enlarged, weighing 25 ounces, owing almost entirely to hypertrophy with dilatation of the left ventricle. When water was poured upon the aortic valves from above, it passed rapidly through the orifice. The aortic valves were thickened throughout and shortened; their curled-in and dense margins were one-tenth of an inch thick. Two of the valves were united at their neighboring surfaces, so as to form one, the only vestige of a septum between them being a hardened nodule at the base of the enlarged valve. On the edge of the smaller valve was a warty excres- cence, the size of a coffee bean, soft in consistence, composed of recent exudation, and infiltrated with blood, so as to present a purple color. There was red hepatization of the posterior and inferior portion of both lungs, and there was considerable apo- plectic extravasation in the substance and the neighborhood of the diseased portions of the lung. The bronchi were filled with frothy mucus. Abdomen.—The liver presented the nutmeg appearance, being in the first stage of cirrhosis. Other organs healthy. Commentary.—We had very little difficulty in determining, from the * Reported by Mr. David Christison, Clinical Clerk. 584 DISEASES OF THE CIRCULATORY SYSTEM. cardiac signs in this case, that, according to the rules laid down, there was incompetency of the aortic valves, with dilated hypertrophy of the left ventricle. The bellows murmur, which was at first soft, gradually changed its character as the case progressed, without altering its position. It became whining, and then chirping, constituting what is called a musical murmur. It is generally found in such cases that a solid body projects into the current of the blood as it flows through the valve so as to be thrown into vibrations; and it was interesting to discover, on the examination of the body, that the vegetation described exactly fulfilled these conditions. From its softness, also, there is every reason to sup- pose it was of recent formation, originating probably about the time the musical murmur was first observed. From the great induration of the aortic valves, there can be very little doubt that they had been affected for a long time, at least many months; but it becomes a question, whether the adhesion and formation of one valve out of two might not have been caused by a rupture of one or both valves, two months pre- viously, at the time he was lifting heavy stones, and was suddenly seized with cardiac pain and other symptoms. It is worthy of observation, also, that, although he had cerebral symptoms, the lungs were greatly affected, the bronchitis latterly passing into pneumonia with pulmonary hemorrhage. Case CXI.*—Mitral Incompetency—Hypertrophy of Left Ventricle— Dilatation and Disease of Arch of Aorta—Aortic Incompetency. History.—Hugh Devine, set. 40, laborer—admitted July 17, 1850. Dates his illness from a severe strain of the back, eighteen months ago, but is not sure when he first noticed dyspnoea and palpitation, which have prevented him from working for the last eight months. Never had rheumatism or haemoptysis. Symptoms on Admission.—Cardiac dulness measures two and three quarter inches transversely. The apex beats between the fifth and sixth ribs, two inches below and a little to the right of the nipple. A bellows murmur with the first sound is heard at the apex decreasing towards the base. A bellows murmur of a rougher character is also heard with the first sound at the base, which is prolonged in the course of the large vessels. The second sound is normal. There is distinct pulsation under the clavicles, but none above the sternum. Pulse 104, regular, full, and jerking. No cough or pulmonary symptoms, with the exception of dyspnoea on exertion. Has frequent pain in the upper part of the head and across the temples, and occasional dimness of vision. The thyroid gland is somewhat enlarged. Progress of the Case.—Since his residence in the Infirmary the symptoms have been greatly ameliorated. The dyspnoea, palpitation, and cephalalgia, have nearly disappeared. The cardiac signs, however, have undergone considerable change. On the 16th of August it is reported that there is still a bellows murmur with the first sound, heard loud at the apex. An inch above, and to the inside of the nipple, a loud, harsh, grating murmur is beard with the first sound, and followed by a soft bellows murmur with the second. In the course of the aorta there is unusual impulse, and coinciding with it there is a bellows murmur, which is propagated along the carotids. He was dismissed, September 12th. Commentary.—This man was examined with great care, and cardiac signs ascertained to exist which are not often associated together. For instance, there was a distinct bellows murmur, loud over the apex and diminishing towards the base, which, according to the rules given, we ascribed to mitral incompetency. Over the aortic valves, however, and * Reported by Mr. David Christison, Clinical Clerk. VALVULAR DISEASES OF THE HEART. 585 extending along the arch of the aorta, there was a bellows murmur of a rougher character, and also occurring with the first sound. Now, rule 7 tells us that this may depend on three circumstances,—" 1st, On an filtered condition of the blood, as in anaemia; 2d, On dilatation or dis- ease of the aorta itself; or, 3d, On stricture of the aortic orifice, in which case it is almost always associated with insufficiency, and then the murmur is double." It is clear that the first and third propositions would not apply, and I therefore came to the conclusion that in addition to mitral regurgitation, the aorta was dilated and diseased, the former indicated by the increased impulse, .and the latter by the roughened murmur. Latterly, when dismissed, the roughened murmur over the aorta assumed a rasping character, and a soft bellows murmur was also heard with the second sound—so that the dilated and diseased aorta had at that time probably become associated with aortic incompetency. Case CXIL*—Great constriction of Mitral Orifice—Dyspncea, Palpita- tions, Cough, and Hemoptysis—Loud Pra-Systolic (or Diastolic- Mitral) Murmur—Death followiny Abortion—Enlargement of the two Auricles and right Ventricle—Atrophy of left Ventricular walls. History.—Ann Laurie, aet. 19, a servant—admitted May 2d, 1859. Says that she has always enjoyed good health until four years ago, when she first observed herself to become breathless on making any unusual exertion. Six months afterwards breath- lessness became much worse, and she experienced violent palpitations of the heart when working. Cough and haemoptysis now occurred, for which she entered the In- firmary, and went out in a month nearly well. Eighteen months ago these symptoms returned, and she again entered the Infirmary, was once more relieved, and has re- mained pretty well until a week ago, when the violent coughing and spitting of blood returned, and have continued up to this time. Symptoms on Admission.—There is great dyspnoea, frequent cough, with copious frothy sputum mixed with mouthfuls of pure blood. Pulse 96, weak. Complains of excessive palpitations. Heart's action strong; impulse between the fifth and sixth ribs, an inch below and in a fine with the nipple. A loud prae-systolic murmur is heard at the apex on auscultation. Dry and moist bronchial sounds, with prolonged expiration heard over the whole chest. Face anxious, clammy sweat on the surface. Is a well-nourished girl. No appetite. Great thirst. Diarrhoea, having 6 or 7 stools daily, with tormina. Starts during her sleep, and is subject to dreams. Other systems normal. To have two table-spoonfuls of the chalk and catechu mixture three times daily. Quietness and rest enjoined. Progress of the Case.—May 4th.—Diarrhoea has ceased. Other symptoms alle- viated. On carefully examining the heart it was ascertained that the transverse dul- ness was 2\ inches; that there existed one' prolonged hoarse-blowing murmur, occu- pying the period of both sounds, and terminating suddenly with a jog, immediately before the long pause. The sound also increased in intensity from its commence- ment to its close at the moment of systole. It was heard loudest immediately below the nipple, and over a space about an inch and a half in diameter outside it. Over the sternum though audible it was distant. At the base of the heart the second sound was heard quite healthy. May 6th.—Haemoptysis and dyspnoea had ceased. Cough, expectoration, and other symptoms greatly diminished. June 18th.—Ha3 been in tolerably good health since last report, and the bronchial signs have disap- peared, with the exception of prolonged harsh expiration. Cardiac sounds the same. To-day she complains of rheumatic pains in various parts of the body; and it would seem that in consequence of exposing herself unnecessarily in the lobbies of the house, there was a rigor last night, followed by febrile symptoms. There are now pain in the chest, dyspncea, cephalalgia, and increased action of the heart. Venesectio ad § iv. June 19th.—Bleeding gave great relief to pains in head, chest, and dyspnoea. Has * Reported by Messrs. Wm. Willis, and J. Broster, Clinical Clerks. 586 DISEASES OF THE CIRCULATORY SYSTEM. rheumatic pains in the joints of lower limbs, which, however, are not swollen. Warm fomentations to the painful parts. June 28th.—The rheumatic pains have disap- peared for four days, but this morning haemoptysis returned. July 4th.—Has had no haemoptysis since the 2d. August 3d.—Since last report her general health has been excellent, and she has even been assisting the nurse in her ward duties. Is only sub- ject to occasional palpitations. Was dismissed with careful directions as to how she was to manage herself. Re-admitted, February 13th, 1860.—Has on the whole enjoyed excellent health since she left the bouse, and two months ago was married. Three weeks since, in consequence of the roof of her house being out of repair, she was, during a stormy night, exposed to the rain and wind, which entered her room, and she took a severe cold which induced a return of all her bad symptoms. At present there is fever, bron- chitis, with great dyspncea; no haemoptysis, cardiac palpitation, the prae-systolic mur- mur as loud as ever. Pulse 90, of good strength. R Sp. jEther. Chloric. 3 hi; Tr. Card. C. § ss; Aquam ad § iv. A table-spoonful to be taken occasionally. March 5th.—The acute symptoms have subsided for some time. To-day there is slight haemoptysis. She has not menstruated for two months. April 21st.—Since last re- port has been on the whole well, although from time to time there has been slight haemoptysis. To-day, however, she suddenly brought up about § xxij of blood. Or- dered to remain in bed, and to suck occasionally apiece of ice. April 30th.—Haemoptysis has ceased ; again feels well; cardiac signs the same. May 5th.—Last night she was delivered of a four months' foetus, and expired immediately afterwards. Sectio Cadaveris—Sixteen hours after death. Thorax.—The right side of the heart was much enlarged, in part forming the apex. Both auricles as well as the right ventricle were dilated and hypertrophied. The left ventricle normal in size, its walls thinner than usual. The mitral orifice was round and constricted, so as to be incapable of admitting the top of the little finger. The chordae tendineae of the valves were glued together and shortened. The aorta was smaller in calibre than the pulmonary artery, which was somewhat dilated. The aortic valves were healthy. The heart weighed 11 oz. Slight adhesions of the pleurae on both sides. No recent pulmonary hemorrhage into the lungs, but the lower lobe of the left lung was firm and more crepitant, and on squeezing it after section, a purplish thick fluid escaped, probably the result of old hemorrhagic extravasation. Abdomen.—Abdominal organs healthy. The uterus enlarged and flaccid, the cervix presenting an ecchymosed appearance. Commentary.—The prae-systolic murmur heard in this girl was un- usually loud, and consisted of a rushing sound, increasing in intensity until it was suddenly arrested by a knock or jog synchronous with the systole. It exactly occupied the period of both sounds, completely mask- ing the second sound at the apex, although at the base the latter was heard clearly, following the impulse as usual. In this manner, at the apex there was audible only one long sound and one pause, both of equal length, separated from one another by the abrupt systole. The leading symptoms were palpitations and dyspncea on exertion, together with ten- dency to bronchitis on exposure to cold, with haemoptysis. There is every reason to suppose that the cardiac lesion had originated in rheumatism, as she was strongly predisposed to this disease, and had on one occasion a smart attack of it when in the ward. She was a remarkably well-formed and otherwise healthy girl, the appetite generally good, and nutrition well performed. Her long residence in the Infirmary gave all who witnessed the case ample opportunities of studying the physical signs and symptoms which it presented, and it was observable that quietude, non-exposure to cold, and good diet, always succeeded in restoring her to good health. Very little medication was required. On one occasion I ordered a small bleeding to relieve the palpitation and great congestion of the lungs, which it succeeded in doing at once, this being—as I pointed out in 1857, when VALVULAR DISEASES OF THE HEART. 587 condemning large bleedings in the treatment of pneumonia—a most valuable result of the practice which remained to us. The diagnosis, of mitral contraction, was evident from the first, and how long she might have lived, but for her pregnancy, it is of course difficult to determine. This, by enlarging the uterus, and thereby causing increased embarrassment to the lungs, must have produced grave results at no distant time. Abor- tion, however, occurred about the fourth month of utero-gestation; and although the labor pains did not last above an hour, such was the ex- haustion occasioned that fatal syncope occurred. The post-mortem examination revealed effects not uncommon as the result of extreme con- traction of the mitral orifice—viz., diminution in the size and thickness of the left ventricle, with unaltered aorta and aortic valves, while the other three cavities, together with the pulmonary artery, were dilated. The dilated cavities are at once accounted for, as a result of the obstruc- tion they had to overcome in the lung, and constricted mitral orifice; while the left ventricle often remains of its normal size, and occasionally becomes smaller, or is atrophied, as occurred in the case before us. It was pointed out by Dr. Jenner, that in these cases the muscular tissue of the heart must be congested, in consequence of the pressure on the veins producing, as he thought, peculiar induration and toughness of the hypertrophied walls.* The rushing noise heard during life, previous to the systole, could leave little doubt that it was caused by the passage of the blood from the auricle through the constricted orifice; and it would appear that after this the left ventricle for a long time must have acted quite naturally, as it was observable that the pulse throughout was of good strength, never irregular, and seldom weak, as in cases of incom- petency. Latterly, the walls of the ventricle had become thinner, show- ing that the extreme contraction of the mitral orifice not only acted as a perfect valve, during systole, but must have so removed tension, or the necessity for great exertion, as to have allowed the muscular walls of the ventricle to become atrophied. Many other examples of contracted mitral orifice, with prae-systolic murmurs, have entered the wards; in- deed, the disease is far from uncommon, although Latham considered it a kind of cardiac curiosity, but in none have I ever seen it proceed to so great an extent before death. According to Skoda, the second sound of the pulmonary artery is apt to be intensified in this disease, in conse- quence of the increased force and tension thrown upon its sigmoid valves. No doubt the second sound in these cases is often heard unusually clear, but cannot be separated in point of time from that of the aortic valves. Case CXIILf—Constriction of Mitred and Tricuspid Orifices—Aortic In- competence—Anasarca—Hydrothorax—Collapse of Left Luny— Rrighfs disease of Kidney. History.—Elizabeth King, aet. 26—admitted July 20th, 1855. Two years a«x> she entered this hospital, laboring under an attack of acute rheumatism; was dismissed relieved at the end of six weeks, but soon afterwards she was again laid off work by general anasarca; and in the November of the same year (1853) she again returned to this Infirmary. She was a patient in the Clinical Wards; was treated for double * See Med.-Chir. Trans, of London, vol. xliii. f Reported by Mr. D. M'Gregor, Clinical Clerk. 588 DISEASES OF THE CIRCULATORY SYSTEM. pneumonia; was recognised at that time to labor under mitral insufficiency; was much relieved during her stay, and discharged in the middle of February, 1854. But she has never recovered her strength. Three months ago she became affected with swell- ing of the legs and abdomen, with occasional slight lumbar pain, and with severe pain in the hypogastric region attendant upon the abdominal swelling. The pain and the swelling have gradually become worse. She has been confined to bed for the last ten days. Symptoms on Admission.—Impulse weak; apex beat not definable ; transverse dulness three and a half inches; at the normal site of apex beat there is a double blowing murmur; the same is audible all the way up to the clavicle, but it diminishes in intensity from below upwards. Pulse 86, small and weak; palpitation, vertigo, slight cough; muco-purulent expectoration; dyspnoea on exertion, with occasionally ortbopnoea at night; face slightly livid, with a faint tinge of yellow; is naturally freckled. Has great thirst and little appetite; the bowels are costive. The urine is scanty, of an orange-yellow color; sp. gr. 1015; is not albuminous. The lower ex- tremities and the skin over the hypogastric region are oedematous, tense and painful on pressure. Yesterday had severe pain in the right iliac passing to the lumbar region. Does not sleep well at night. Progress of the Case.—The pain in the right iliac region disappeared under treatment during the first week. Vomiting occurred at every meal during the same period. After the 24th July, the urine contained a large quantity of bile, and the whole body became slightly jaundiced. No increase in urine could be effected. On the 9th August it is reported very scanty and albuminous. The anasarca steadily increased, with painful tension of limbs and abdomen. Ultimately the whole trunk, upper extremities, and face became oedematous. Respiration became more embarrassed, and over the upper parts puerile. On the 8th August there were signs of hydrothorax on the left side. The dyspnoea, cough, sleeplessness, and want of nourishment wore out her remaining strength, and she died September 5th. At first, leeches, followed by warm fomentations, were applied to the hypogastric and right iliac regions to relieve the local pain. Subsequently, diuretics and cathartics were employed to relieve the anasarca, combined with nutrients and latterly stimulants. Sectio Cadaveris.—Eighteen hours after death. Body extremely anasarcous. Thorax.—Heart weighed 10^- ounces, lay unusually transverse, with apex pointing to left side. The right auricle was dilated, especially the auricula; the foramen ovale within the annulus was not patent, but the membrane was pushed back into a pouch; its lining membrane was much thickened. The tricuspid valves were thickened at their margin, and so constricted that the first joint of the little finger up to the root of the nail could alone pass. The pulmonary valves were quite healthy. The left auricle was not dilated; the mitral valves were thickened and constricted so as only to admit the first joint of the little finger up to about the middle of the nail; the tendinous cords were so shortered that the valves appeared to be fixed directly to the summit of the columnae carneae. The aortic valves were also thickened (more at the margin than the base) so as to be inelastic and incompetent. Both ventricles hypertrophied and dilated. The left lung was collapsed ; about one pint and a half of fluid in the pleural cavity. The right lung was adherent throughout, especially at the base, to the diaphragm; the diaphragm itself was adherent to the costal pleura from the sixth rib downwards. On section, the lung appeared very oedematous in some portions, and in others collapsed. Abdomen.—The liver was fatty; weighed 2 lb. 10£ oz. The spleen seemed healthy. The kidneys were atrophied, especially the right, which weighed 2\ ounces; and on section presented a good specimen of the hard, contracted, and granulated kidney of Bright. In the left kidney only one cone was disorganized. The uterus and ovaries were normal, and the intestines healthy. Case CXIV.*—Constriction of Mitral and Tricuspid Orifices—QZdema— Hemorrhage into the Lungs. History.—William Page, aet. 20, ploughman—admitted August 30th, 1852. States that nine months ago, while carrying a heavy sack of grain on his back up a flight of * Reported by Mr. William Calder and Mr. David Milroy, Clinical Clerks. VALVULAR DISEASES OF THE HEART. 589 stairs, his foot slipped, and he fell with the load upon him. Asserts that he was insen- sible for a fortnight afterwards, and on recovering was affected with cough and bloody expectoration for a month. He has also been constantly liable to palpitation, dys- pncea, and starting from sleep, and been unable to ascend stairs in consequence of the violent palpitations and feeling of faintness thereby produced. Says he was in perfect health at the moment of the accident, and never had rheumatism. He has been sub- jected to various kinds of treatment, and been salivated with mercury without any benefit. Symptoms on Admission.—Apex of the heart beats distinctly in the intercostal space between the sixth and seventh ribs. The impulse is strongest in a line drawn vertically from the nipple—is full and rather diffused. The pulsations at the heart are more numerous than those at the wrist. On percussion the cardiac dulness measures three and a half inches across. On auscultation a prolonged blowing murmur is audible with the first sound at the apex, which decreases in intensity towards the base of the organ, and is entirely lost at the commencement of the great vessels. Second sound normal. Pulse 72, full, not hard; and there is an occasional small, sharp beat occur- ring after every five or six of the ordinary pulsations. Breathing slightly accelerated, amounting to dyspnoea on the slightest exertion; occasional cough, followed by tough mucous expectoration, interspersed with a few points of dirty rusty color. Percussion normal and auscultation over lungs only elicits a few scattered sibilant and sonorous rales, posteriorly on left side. The appetite has been diminished, with occasional vomiting for the last three months. Is apt to start hurriedly from sleep after lying down, and is disturbed by dreams. Slight oedema of the feet and ankles. Urine healthy. Other functions normal. Progress of the Case.—During the months of September and October the symp- toms gradually increased. The dyspnoea became more urgent, and the paroxysms more frequent. The cough with bloody expectoration, the oedema, general weakness, and palpitations were all augmented. There has also been occasional vomiting, and the skin has assumed a yellow jaundiced hue. He had again been put under a mercurial course, and a variety of remedies were employed to relieve cough and spasm, all of which produced only temporary relief. On taking charge of the case on the 1st of November, I found a loud blowing murmur occupying the period of both sounds at the apex, the impulse of which was felt between the fifth and sixth ribs two inches in a straight line below the nipple. Over the xiphoid cartilage the second sound was determined to be healthy, immediately following the blowing with the first. At the base also the second sound was heard distinctly normal, and the blowing with the first sound, though still loud, more distant. Sputum was gelatinous, deeply tinged with fluid blood. Anteriorly the chest was resonant, but inferiorly and posteriorly percus- sion was slightly impaired, with occasional crepitating rale and double friction. Pulse 120, feeble, and irregular; great weakness. Nutrients with wine. November 12th.—Is worse. Great lividity of face and orthopnoea. Heart's action so tumultuous that no individual sounds can be distinguished. Extremities oedematous and cold. Pulse im- perceptible. In this condition he continued until the 15th, when he died. Sectio Cadaveris.—Forty-four hours after death. Body not emaciated; surface considerably jaundiced. Thorax.—Pericardium contained several ounces of serum. Heart much enlarged, especially on right side. Right auricle the size of a large orange. Left auricle also considerably distended. Both ventricles dilated, the walls not much hypertrophied. Endocardium of left auricle thickened and opaque. Mitral valve constricted, its edges rigid, and partly calcareous, so that it could only admit one finger. The tricuspid valve was also constricted, so as scarcely to admit two fingers. This was owing to thickening and shortening of the valvular segments, which were also abnormally ad- herent to each other at their extremities. At the edge of one valve were a few rough granulations of lymph. Aortic and pulmonary valves healthy. Both lungs were emphysematous anteriorly, but the dilatation of individual air-cells was not extreme. In the posterior and inferior portions were irregular condensed masses of hemorrhagic extravasation, varying in size from a walnut to a hen's egg. Interspersed through the lungs generally were several miliary tubercles. The pleurae were adherent in sev- eral places, and also contained a few tubercles. The trachea and bronchi were loaded with viscid muco-purulent matter. 590 DISEASES OF THE CIRCULATORY SYSTEM. Abdomen.—Liver congested, presenting to a certain extent the nutmeg appearance. Kidneys and other abdominal organs healthy. Commentary.—In both these cases careful examination of the heart did not enable me to form a conjecture that the tricuspid valve was diseased. In the first case, the continuous blowing at the apex completely masked the second sound, even at the base of the organ. In the other case, while the blowing occupied the period of both sounds at the apex, the second sound was audible towards the right, over the xiphoid cartilage. In the case of King, there was also incompetency of the aortic valves, but in both the auriculo-ventricular valves were the chief seat of disease. The symptoms were not unlike, and were characterized by excessive palpitation; great dyspnoea, with oedema of the lungs in one, and hemorrhage into the lungs in the other case; vomiting, dropsy, and jaundice. None of which symptoms, however, either individually or collectively, can be said to indicate tricuspid as distinguished from mitral lesion. The origin of the two cases was widely different. The one de- pendent apparently on rheumatic endocarditis, the other caused by a fall and contusion, although how this should have affected both auriculo- ventricular valves is by no means clear. The utility of mercury was fairly tested in Page's case, and as usual found to be of no benefit what- ever. Theoretically it is impossible to understand how this drug is to diminish thickening of the valves or contractions of the chordae tendineae, and practical experience has utterly failed in demonstrating its ad- vantage in endocarditis any more than in pericarditis. Case CXV.*—Soft Adherent Polypus, causiny incompetency of the Mitral Orifice—Anasarca. History.—William Taylor, aet. 50, a compositor—admitted December 20th, 1852. The patient enjoyed good health till a year ago, when be became subject to attacks of vertigo. The first of these came on after a long race; they recurred frequently, especially after meals. Three months ago, cough and dyspncea came on, which have gradually become worse. Two weeks ago, his legs began to swell, and Ave days ago the lower part of both legs became of a purple color, not disappearing on pressure, the rest of the skin of the body assuming a yellowish hue; these discolorations have since increased. Has suffered much mental distress during the last six months. Symptoms on 'Admission.—Cardiac apex in normal position; impulse somewhat increased. With the first sound there is a blowing murmur heard loudest at the apex; second sound normal; transverse dulness normal. Pulse very small and weak, 120 per minute. Percussion of the lungs normal; breathing hurried, respirations being 40 per minute; no abnormal sounds audible on auscultation. Sleeps badly and is very weak. Tongue slightly furred; appetite bad; bowels constipated; stools dark colored. Urine in goodly quantity, high colored, loaded with lithates; contains a slight amount of albumen. Legs swollen. Ordered to have § iv of wine and diuretic mixture. Progress of the Case.—December 23d.—Crepitation over lower hah of both lungs posteriorly; no dulness or increased vocal resonance. Expectoration streaked with' blood. Weakness great; pulse hardly perceptible. Ordered expectorants and | vj of wine. 24th.—Urine passed in very small quantity. Ordered diuretics with nitric ether and half the wine to be replaced by an equal quantity of gin. 25th.—Was delirious last night, and suffered from dyspnoea. Died this morning at half-past eleven. Sectio Cadaveris.—Forty-eight hours after death. Thorax.—The pericardium contained about an ounce of turbid yellowish serum. The heart was slightly enlarged on the right side. All the cavities were full of blood, * Reported by Mr. R. Brown, Clinical Clerk. VALVULAR DISEASES OF THE HEART. 591 partially coagulated, the coagula being soft and colored throughout. In the left auricle was a soft, gelatinous, semitransparent mass, the size of a pigeon's egg, which hung over the mitral orifice, and appeared to choke it up. It was firmly attached to the membrane of the auricle by a surface about half an inch square, in substance resem- bling colloid, and externally was not unlike a soft polypus, or a mass of uterine hyda- tids ; on section, it was homogeneous, and consisted of a fibrous stroma, which could easily be torn, enclosing between its meshes a clear viscous fluid. The flaps of the mitral valve were somewhat thickened, without deformity or thickening of the chordae tendineae, which, with the columnae carneae, were quite healthy. The other valves were normal. The lungs were oedematous, with small hemorrhagic patches at various points. Abdomen.—The peritoneal cavity contained about half a gallon of clear serum. There was slight hepatic congestion of the liver, but the other abdominal viscera were unfortunately not examined by the pathologist. Microscopic Examination.—The attached polypus in the left auricle consisted of bands of fibrous tissue, crossing one another and forming oval and circular areolce containing a viscous serum. Embedded in these bands were nucleated cells, round, oval, and fusiform in shape. Some of the latter were lengthened out into* fibres. They were fibre-cells exhibiting every stage of transformation, from the rounded cell up to that of perfect areolar tissue. Commentary.—The structure and firm attachment of the polypus in this case, can leave us in no doubt that it must have existed some time before death, and caused the symptoms of which this man complained. From its position it appeared calculated materially to interfere with the passage of the blood from the left auricle to the left ventricle, but the sound, during life, indicated an incompetency rather than a narrowing or stricture of the auriculo-ventricular orifice. To it, however, the excessive dyspnoea, which was the chief character of the case during life, was most probably owing. The mass itself closely resembled, to the eye as well as under the microscope, some kinds of simple colloid I have seen; whether it originated in an exudation, in a deposition of fibrin from the blood, or in a combination of the two, it is difficult to determine; the last supposition is the most probable. That coagula are formed from the blood in the cavities of the heart during life, there can be little doubt, although we are ignorant of any means of detecting them. They have been supposed to be the result of endocarditis. If so, we must suppose that an exudation thrown out on the endocardial lining membrane causes roughness, which, as the blood flows over it, tends to produce fibrinous deposition from that fluid. However formed, two subsequent changes may occur—1st, Fibre cells may be formed in it, and the whole gradually developed into a fibrous structure, as in Case CX V. This is very rare. More commonly it softens in the centre, and is gradually reduced to a fluid, which to the naked eye closely resembles pus. Such collections have been called "purulent cysts." I have frequently examined the contents of these cysts, and have no doubt that, in many cases, the so-called "purulent cysts" are simply formed by a mechanical disintegration of the clot, in the manner first described by Mr. Gulliver, and are not purulent cysts at all. I once found a pyriform clot in the right ventricle of the heart, firmly attached to the endocardium by its smaller extremity. It was the size of a hen's egg, and on cutting into it there flowed out two ounces of a fluid exactly like good laudable pus. Yet it did not contain one pus corpuscle, but was wholly made up of molecular matter, associated with the broken down debris of a fibrous clot, and a few collapsed colorless cells of the 592 DISEASES OF THE CIRCULATORY SYSTEM. blood. In this way a microscope demonstrates, not unfrequently, that what was regarded as pus, and considered a proof of inflammation, is in truth quite unconnected with the latter process, and is owing to alto- gether different causes. Case CXVIft—Enlarged Foramen Ovale—Phthisis. History.—James M'Queenie, set. 27, a tailor—admitted June 23d, 18£3. Has never been a strong man, having been very liable to suffer from colds and indigestion. Since boyhood he has been liable to palpitation and dyspncea on the slightest exertion. His health, however, continued pretty good till eighteen months ago, when he was ad- mitted into this Infirmary. He then labored under inflammatory fever, with cough and pains in the chest; there was evidence of condensation of the apex of the right lung; and obscure shifting murmurs were heard with the cardiac sounds, which led to the belief that the patient was suffering from subacute pericarditis in the course of tubercular disease. He was treated with aconite, and afterwards with mercury. He became much better, but did not entirely regain his health; the physical phenomena remained as before; cough and expectoration also continued. Of late these symptoms have become more troublesome, so as to induce him to re-enter the Hospital. Symptoms on Admission.—Apex of the heart beats slightly to the right of the usual position; transverse dulness three inches; sounds feeble and indistinct; with the first and running into the second, there is a peculiar whizzing, neither a blow- ing nor a friction murmur; it is heard most distinctly at the base, is not constantly present, and is not propagated along the large vessels. Heart's impulse feeble, and producing a wavy motion under three intercostal spaces. Palpitation on exertion or mental excitement. Pulse 90, small and slightly intermittent. Under the right clavi- cle, dulness on percussion, with increased sense of resistance, and imperfect cracked- pot sound; on auscultation there are loud moist rales almost gurgling in character; much prolonged expiration; loud bronchophony. Towards the lower margin of the right lung there is harsh respiration with sibilus. Below the left clavicle for a hands- breadth there are fine moist rales with prolonged expiration and loud vocal resonance; sibilus also, as on the right side. Posteriorly the signs correspond to those in front. Sputum abundant and muco-purulent; cough frequent, but not harsh; breathing easy. Appetite scarcely impaired. Occasional diarrhoea, now checked by astringents. He- patic and splenic dulness normal. Great sweating at night. Urine of normal charac- ter. Ordered to take cod-liver oil, and to have nourishing diet. Progress of the Case.—June 23d to July 13th.—Treatment as above; strength much increased. Yesterday had a rigor, followed by stitch in the side; it was relieved after the application of leeches. July 13th-23d.—Has gradually become much worse. Suffers now from great dyspnoea, frequent cough, copious expectoration, night sweats, loss of appetite, diarrhoea, and great weakness. No great change in the physical signs; the heart sounds are much masked by the pulmonary rales. Has taken cod-liver oil, with occasional antispasmodics and astringents, and latterly § iv of wine and § ij of brandy in the course of the day. July 24th.—Gradually sunk, and died at twelve noon. Sectio Cadaveris.—Twenty-five hours after death. Body much emaciated; rigor mortis moderate. Thorax.—No adhesions between the layers of the pericardium, or between the pleura and that membrane. The pericardium contains about two ounces of turbid yellowish fluid with small flocculi of lymph. Surface of the heart presents a milky patch the size of a shilling towards its base posteriorly, and there are some smaller ones over left auricle. Heart soft, flaccid, and fatty; it weighs twelve ounces. The right ventricle is much dilated and the walls are thin; the tricuspid orifice admits four fingers with ease; mitral valves very slightly thickened at the margins, but otherwise healthy; aortic valves healthy. In the septum auricularum there is a large opening which can admit three fingers; evidently the foramen ovale much enlarged; * Reported by Mr. W. M. Calder, Clinical Clerk. VALVULAR DISEASES OF THE HEART. 593 it is oval in shape, and the edges are smooth and rounded. Pulmonary artery dilated; calibre of the aorta diminished, and only half the size of the pulmonary artery. Right lun°- adherent all over. Adhesions firmest near the apex. The lung is non-crepitant throughout, and everywhere infiltrated with tubercle, which is most chrome at the apex,"where there are several puckerings and dense cicatrizations. The left lung also infiltrated with tubercle, but not to so great an extent, and more recent. Abdomen.__The liver was much congested, with a linear cicatrix two inches long, situated half an inch anterior to its diaphragmatic attachment. The lower third of the ileum with the caesium and ascending colon, the seat of numerous tubercular ulcera- tions.' A few tubercular deposits in the mesenteric glands. Other organs normal. Commentary.—The peculiarity of the cardiac sounds in this ease, consisted in the existence of a kind of whizzing murmur, synchronous with the systole, and loudest at the base, combined with palpitations, feeble impulse, and a weak intermittent pulse. This combination of signs and symptoms forbade the supposition that the lesion was aortic, while the sex, and absence of murmur in the larger vessels, were opposed to the notion of its being anaemic. After death a large opening was found between the auricles, with smooth edges, which must have admitted the ready flow of blood through it. Whether the peculiar whizzing sound—which was neither loud nor constant—was caused by this open- ing, it is difficult to say, but judging from its situation and character, this is not improbable. The slight thickening of the flaps of the mitral valve did not seem to interfere with its competency, and certainly caused no murmur. Few well-observed cases of patent foramen ovale in the living subject have been recorded. In one recorded by Dr. Markham,* the open fora- men ovale allowed the blood to pass readily from the right to the left auricle, but not in the opposite direction, excepting through two narrow slits. There was audible during life a loud, rough, and prolonged sys- tolic murmur over the whole pericardial region, over the upper part and along the right border of the sternum, and in the whole of the upper half of the interscapular space. From an inquiry by Dr, John Oglef into this subject when he was Curator of the Pathological Museum at St. George's Hospital, he found that of thirteen cases of patent foramen ovale, it was stated in seven that no murmur synchronous with the sys- tole existed. The size of the openings is not given. In one other case, a diastolic murmur was present, owing to undoubted disease of the aortic valves. Hence, of the whole thirteen, there was no evidence that this lesion produced a murmur at all. Dr. Markham's case being uncompli- cated and well observed, affords pretty strong evidence that a murmur may, under certain conditions, be occasioned by open foramen ovale, as does the one now recorded. But what those conditions are, as well as a crowd of interesting points in connection with them, can only be deter- mined by future observations. Since the above observations were written, Dr. Foster of Birming- ham has published two cases of patent foramen ovale, in children with cyanosis, in both of which a murmur with the first sound was audible over the base of the heart.J Dr. Reish, also, of Vienna, has given a case * British Medical Journal, April 4th, 1857. \ Ibid., June 13th, 1857. \ Dublin Quarterly Journal, August 1863. 38 594 DISEASES OF THE CIRCULATORY SYSTEM. associated with mitral lesion, in which there was a loud systolic murmur at the apex of the heart, and a weak indistinct second sound. Over the lowest part of the sternum no murmur was audible, but two weak sounds were heard.* Here the case being complicated, nothing very de- finite was arrived at. Patholoyy of Valvular and Organic Diseases of the Heart. The lesions producing valvular disease of the heart are various, and may be referred to mechanical violence, to the effects of exudation, acute or chronic, to deposition of fibrin, and to the different forms of degene- ration of texture. But however occasioned, they all tend to produce subsequent changes in the texture and vital actions of the heart itself; above all, hypertrophy and fatty degeneration of its muscular walls, with increased, diminished, or irregular contractions of its cavities. Although it is with these latter that the physician has principally to do, a know- ledge of the former is essential to the correct appreciation and proper treatment of every individual case. Mechanical injuries not unfrequently occasion sudden disease or rup- ture of the valves (Cases XCIX. and CXIV.), separating their attach- ments, and causing subsequent adhesions and fibrinous depositions. Great muscular exertion has also occasioned similar results. (See Case CIIL). Four cases of this are recorded by Dr. R. Quain,f in one of which a smith, when working vigorously, experienced " an uneasy shaking of the heart," shortness of breath, and heard a peculiar noise " up his chest, neck, and in his ears." On examination, a loud ringing musical murmur was heard over the aortic valves with the second sound, and there was a softer blowing with the first sound. After suffering two years, during * Edinburgh Medical Journal, February 1863, p. 752. f Monthly Journal of Medical Science, December 1846. Fig. 436. Conjoined attachment of two of the aortic valves at a, separated from the aorta at b. Here the wall of the vessel was raised into a superficial elevation. At c, the margin of one valve was slightly everted, and studded with small granulations.— (P. Quain.) VALVULAR DISEASES OF THE HEART. 595 which the sounds underwent different modifications, followed by cardiac hypertrophy, he died, and on dissection, the conjoined attachments of two of the valves to the aorta were found to be separated from the wall of that vessel, so that they dropped below the level of the third, which retained its connections (Fig. 436). Cases of this kind would perhaps be more frequently observed, if the origin of valvular diseases were more carefully looked for. Exudation into or on the surface of the valves, constituting the endo- carditis of systematic writers, is a common cause of valvular disease. If acute, it may appear in the form of minute granulations, or forming a layer, varying in thickness and shape, on the surfaces or on the edges of the valves. If chronic, they are firm, and not unfrequently associated with an exudation which has also occurred in the texture of the valve itself, causing more or less thickening or induration in its various parts. In the same manner the chordae tendinese may become thickened and Fig. 437. Fig. 438. shortened from interstitial exudation. As a result, the edges of the valves do not come into accurate contact, and become incompetent to fulfil their functions. After a time, in consequence of excess of exuda- Fig. 4S9. tion and subsequent contraction, the orifices are narrowed, and mechan- ical obstructions offered to the free passage of the blood through them. Fig. 437. A, Aortic orifice with one valve of a funnel-shape, seen from the front. B, The same valve seen from above, showing the original septa of the valve united together.—(Peacock.) Fig. 438. Two valves at the aortic orifice, with a rudimentary one interposed.— (Peacock.) Fig. 439. Congenital malformation of the aortic valves. A, The aorta slit up length-ways. B, Transverse section of the aorta just above the valves.—(Brinton.) 596 DISEASES OF THE CIRCULATORY SYSTEM. In the aortic valves, in addition to the thickenings and contractions, adhesions may occur, with or without the lacerations of septa formerly noticed. In jj this manner there may Ip'l be two, rarely only "H|| one valve from lacera- / tion of the attachment to the aorta and sub- sequent adhesion of the FiSi 440. broken edges. In Fig. 437 the union of all the valves has resulted in the formation of one valve of a funnel-shape. In Fig. 436, two valves have, as it appears, been broken into one another and united together, so as to form one. In Fig. 439, one of the valves seems to have b3en abortive, or not developed. Again, the num- ber of valves may Fig. 441. be multiplied in consequence of adhesions being formed, and extra gift Fi?. 442. Fig- 4i3- pouches thereby established. Thus four valves are occasionally met Fig. 440. Four valves at the aortic orifice, from adhesion of one to the wall of the vessel, so as to form two pouches. Fig. 441. Five valves, formed from adhesions and production of septa in two valves. —(Peacock.) . .. Fig. 442. Mitral orifice, constricted so as to form an elongated and rigid slit re- sembling a button-hole. Seen from the auricle. Fig. 443. Mitral orifice, greatly constricted, so as to form an oval aperture, at the bottom of a funnel-shaped depression. Seen from the auricle. VALVULAR DISEASES OF THE HEART. 597 with, as in Fig. 410. Sometimes these are of uneqnal size, and are then most commonly the result of disease. But I have seen four valves, all exactly like one another, in which case the malformation appears to be congenital. I only know of one instance in which five valves existed at the aortic orifice, and that is given by Dr. Peacock, in his valuable work on " Malformation of the Human Heart, 1858," and which is copied (Fig. 441). The excess is owing to the division of two valves, the super- numerary segment being imperfect. The mitral valves, in addition to roughnesses and thickenings of the valves themselves, and various alterations of their edges in consequence of shortening of the chordae tendineae, present in chronic cases a great tendency to contraction of the orifice. On looking down into the auricle these constrictions of the auriculo-ventricular orifice are seen to assume two shapes, the one being only, however, a greater degree of contraction than the other. In the first it exhibits a slit, or button-hole appearance, in the other a rounded or oval aperture—both openings being at the base of a funnel-shaped depression, caused by the adhesion, thickening, and contraction of the edges ot the two valves. Deposition of fibrin from the blood may occur on the valves in con- sequence of laceration, or of exudations; but sometimes, so far as can be ascertained, without organic lesion. It has been experimentally proved, that the introduction of a thread across the aortic aperture, will cause the precipitation upon it of the fibrin of the blood.—(Sirtion). Any rough surface will produce the same effect. Indeed, there is every reason to suppose that when the blood abounds in fibrin, as especially occurs in acute rheu- matism, such deposits may take place on the valves themselves, without any pre- vious lesion of them, an occurrence which would serve to explain the relation be- tween rheumatic and cardiae disorders. Be this as it may, there can be little doubt that such rheumatic constitution of the blood once established, fibrinous deposits are apt to be thrown down, which con- stitute the vegetations so frequently found at the edges of the valves, resembling soft warty tumors, obstructing the ori- fices, and occasionally hanging down by peduncles into the ventricle. (Fig. 444)* Fig. 444. Degeneration of the valves may occur in various ways, and in its nature be albuminous, fatty, or mineral. Thus the thickening and in- * See some excellent lectures on this subject by Dr. Richardson. British Medical Journal, 1860, p. 21. Fig. 444. Fibrinous vegetations, and atheromatous degeneration of an aortic valve with rupture. 598 DISEASES OF THE CIRCULATORY SYSTEM. durations owing to chronic exudation, may assume a density equal to ligament or fibro-cartilage. Or, on the other hand, they may soften, undergo the fatty degeneration, and at length ulcerate, forming one or more perforations through the membranous portion of the valve (Fig. 444). Lastly, it is by no means uncommon to find that the thickened valves have undergone the mineral degeneration, presenting nodules and masses of earthy matter, varying in size, more or less rough, resembling concretions, and obstructing the orifice in proportion to their size. The immediate result of all these different lesions is, that the valves being incompetent, and not closing perfectly, the blood regurgitates back into the ventricles or auricles at each systole or diastole, according to the valve affected; or if there be contraction and obstruction at the orifice it is propelled forwards with difficulty. In either case, increased mus- cular effort is required to carry on the circulation, and the result is the greater or less enlargement of the heart or hypertrophy. Hypertrophy of the heart may arise from several causes; but by far the most common is disease in one or more of its valves. In this case, it follows the law of increased growth formerly referred to (p. 186), whereby parts subjected to unusual exertion or increase of function aug- ment in bulk. Hence either disease of the aortic or mitral valves in- duces hypertrophy, with dilatation of the left ventricle, from the neces- sity of increased action. The same causes operate on the other parts of the organ. Chronic bronchitis and emphysema, by impeding the circu- lation in the lungs, produce similar enlargements in the right ventricle, and so on. In chronic heart diseases, it is rare that the lesion is con- fined to one cavity, because, as it advances, it produces increasing em- barrassment in the others. Thus hypertrophy of the left ventricle, in consequence of aortic disease, after a time induces enlargement of the left auricle; this embarrasses the return of the blood from the lungs, causing congestions and derangement of those organs. These in turn induce enlargement of the right cavities of the heart, and then the return of blood from the systemic circulation is impeded, causing congestions in the liver and other viscera. In consequence of the over-distention of the venous capillaries so occasioned, effusion of serum occurs, producing oedema, and more or less anasarca. As the dropsical fluid so occasioned augments, the pressure it produces interferes still more with the action of the kidneys, skin, lungs, etc., until at length life can no longer be maintained. These effects will follow more rapidly if, in addition to the aortic, the mitral valves are disordered, or if further complications add to the gravity of the case. Thus the triscuspid orifice may also be affected (Cases CXIII. and CXIV.); or there may be adherent pericardium, or aneurism of the large vessels. Again, the course of these changes may be modified or inverted. The disease, for instance, may commence in the lungs or liver, and, by the obstructions to the circulation thereby occasioned, may affect the heart secondarily. Or, conjoined with val- vular disease and cardiac hypertrophy, there may be primary lesions of the lungs, kidney, or liver. It is by pathological knowledge alone that the influence and mutual dependence of these various derangements can be understood, and a treatment judiciously directed to their relief. Fatty Degeneration of the Heart.—The heart may be loaded and VALVULAR DISEASES OF THE HE AET. 599 even more or less infiltrated with adipose tissue, producing one form of fatty degeneration. By far the more important form, however, is the lesion, for a knowledge of which we are indebted to the recent researches of histologists, and more especially in this country of Paget, Ormerod, and Quain. Of its nature I have already spoken (p. 254). It may occur as a sequela of every form of cardiac disease, but especially when the aortic valves are affected, as well as from a modification in the general condition of the system leading to fatty degeneration of a number of other organs. It may be observed, for instance, in cases where the liver and kidneys are fatty, that the muscular substance of the heart is commonly fatty also. Indeed, there is no degeneration of texture more common than that of fatty heart, which, existing in various degrees, is dangerous in proportion to its intensity, extent, and complication with other diseases. In elderly persons more especially this degeneration may proceed to a great extent without even being suspected, and then some unaccustomed exertion, by demanding from the organ more forcible mus- cular contractions than it is capable of exerting, suddenly arrests its action, and fatal syncope is the result. Many cases of sudden death formerly ascribed to " apoplexy," or " spasm of the heart," may now be confidently affirmed to have been owing to this lesion. Its detection in the living body cannot be made with confidence. Slowness and feebleness of the pulse have been by some thought diagnostic. But many extreme cases of this degeneration have died under my observation without any such symptom. It may cause rupture of the heart and fatal hemorrhage. Myocarditis, or true inflammation of the substance of the heart, is one of the rarest organic diseases known. "Whether, in cases of pericar- ditis, the muscular substance below the serous membrane is the seat of an exudation, is yet to be determined by histological research. The intro- duction of the term " Parenchymatous inflammation," employed by Vir- chow, can only cause confusion, without in any way advaneiug our knowledge, as, in truth, it is no inflammation at all, but the fatty de- generation of the muscular fasciculi just referred to. Treatment of Valvular and Organic Diseases of the Heart. That the various lesions of the valves are susceptible of being removed by drugs, is one of those notions which the advance of diag- nosis and pathology has happily expelled, and which seems now almost universally admitted. All that the practitioner can hope to accomplish, is to modify, and, if possible, check those resulting phenomena from which real danger is to be apprehended. But here much misconception has prevailed as to the real object to be kept in view, or rather the phenomena themselves have been wrongly interpreted by medical men. We have seen that valvular disease leads to dilated hypertrophy; this is accompanied by excessive action, and, especially if the aortic valves are diseased, by a strong, jerking, and hard pulse. The notion is very general that, simply because the pulse is strong, it is the mission of the practitioner to make it weak; that, because the heart acts violently, it ought to be made to beat quietly by lowering remedies. But the strong pulse and enlarged ventricle in the one case, are wise provisions of 600 DISEASES OF THE CIRCULATORY SYSTEM nature, set up to counterbalance the otherwise fatal consequences of the valvular obstruction ; and the violent action of the heart in the other is a proof of weakness rather than of strength, and, instead of being lessened by bleeding and antiphlogistics, requires for its removal tonics, nutrients, and calmatives. To no one is medicine more indebted for making this proposition intelligible than to Dr. Corrigan,* and his views and prac- tice have been acted upon to a great extent by those who have sedulously cultivated the physical diagnosis of diseases of the heart. It is the at- tempt to treat mere symptoms without a knowledge of the organic diseases on which they depend that leads to mistakes among medical men. But with that knowledge, their judicious treatment of the effects of valvular disease of the heart, forms one of the best ex- amples of a modern scientific as distinguished from a former empirical practice. What, then, we have principally to attend to in valvular diseases of the heart, is to do all in our power to support the normal strength of the economy, and avoid agitating the patient, instead of lowering the pulse, or giving mercury under the idea that thereby we are putting down an inflammation or causing absorption of the exudation. In this way persons affected with cardiac disease have continued to live quite unconscious of it for many years in comfort. If, however, it occasion dyspncea, care must be taken to avoid sudden or great exertion, and violent emotions; while by means of diet properly regulated, and by jrentle exercise, a due supply of blood is maintained, and its unequal distribution between the lungs and liver prevented. Pain, angina, and paroxysmal attacks may be relieved by the cautious use of morphia, digitalis, aconite, and other sedatives, used as palliative, and occasionally by carminatives. (Case XCVIII.) When dropsy appears, we may delay its advance, and often get rid of it for a time, by means of diuretics, sudorifics, and even, if the strength admit of it, by drastic purgatives. According to Stokes, the action of these remedies may occasionally be assisted by mercurials. For any other purpose they are useless. When hypertrophy exists to any great extent, and there is obvious difficulty in propelling the blood through the lungs, as evidenced by excessive dys- pnoea, lividity of the face, and irregular heart's action, the application of a few leeches, or cupping to the extent of four or five ounces of blood, frequently gives great relief for a time. Even dry cupping is often beneficial. If there be a tendency to faintness, or reason to suspect fatty disease of the heart, in addition to the other kinds of treatment referred to, a stimulant should always be at hand to be administered at the first approach of syncope. FUNCTIONAL DISORDERS OF THE HEART. What are called functional disorders of the heart, are in fact only symptoms of obscure organic diseases, of indigestion, or of weakness of the general system from alteration of the blood. They assume three principal forms :—1st, Angina pectoris, or spasm of the muscular walls * Edin. Medical and Surgical Journal, vol. xxxvii., 1832. ANEURISM. 601 of the heart, causing excruciating pain and a feeling of sinking difficult to describe. It is generally induced by exertion. We have seen it accompany organic disease of the organ (Case CIX.), and it has been frequently observed in connection with fatty heart and calcareous de- generation of the coronary valve. 2d, In chlorosis, and the anaemia of vouno- women, there are palpitations with a tendency to syncope, accompanied by a blowing murmur at the base with the first sound, of soft character and not permanent. It is propagated in the course of the large vessels, on placing the stethoscope over which, a continuous buzzino- or humming-top murmur is audible (Emit de diable of the French). The cause of this is very obscure, and is by some said to be arterial, and by others venous. (See Diseases of the Blood.) 3d, Similar palpitations, often with a small heart, in young men who follow sedentary pursuits, especially students of the learned professions. Their appetite is generally defective, the body weak and indisposed to exertion, the mind and nervous system irritable, and the sleep pre- vented by the excessive action of and uneasy sensations attributed to the heart. The treatment in all these cases is, when it is dependent on weak- ness, to increase the vigor of the constitution by nutrients, proper exer- cise, and the administration of chalybeates. In chlorosis, more especially, the different preparations of iron are beneficial. In young men regulated exercise, suspension from study, attention to diet, and especially re- moving the attention from the heart at night by cheerful conversation, or interesting light reading, are the most useful means of removing the disorder. In all cases the concomitant derangements must be studied, and, if possible, removed—such as amenorrhoea, haemorrhoids, sperma- torrhoea, dyspepsia, etc. etc. ANEURISM. Case CXVIL*—Aneurism of Aortic Valve, coincident with a Systolic Murmur at the Rase of the Heart—Pneumonia-Meningitis. History.—Margaret Lamont, ost. 36—admitted May 15th, 1861—laboring under all the signs and symptoms of acute pneumonia, of six days' duration, and which, on admission, involved the whole right lung from apex to base. Pulse 100, of moderate strength. It was observed that the first sound of the heart was prolonged, but unac- companied by murmur. She was treated with nutrients and a moderate amount of wine (| iv daily). Progress of the Case.—She was progressing favorably, the greater portion of the formerly hepatized lung being resonant on percussion, and giving out healthy breath sounds, when on May 22d she complained of severe cephalalgia, nausea, and febrile symptoms. The pulse was full, regular, and slightly jerking, 69 in the minute. The chest was carefully examined physically with the following result. " There is still comparative dulness over the upper third of right lung anteriorly. Crepitation has dis- appeared from every part of the chest. There is now a murmur with first sound of the heart at its base, and on placing the stethoscope above the right clavicle, between the insertions of the mastoid and trapezius muscles, there is a loud blowing murmur synchronous with the pulse." May 23d.—In the afternoon experienced a distinct rigor, and on the following day the cephalalgia was much increased, and all the symp- toms of acute meningitis developed. On the 25th twelve leeches were applied to the temples, without causing any relief. On the 26th she refused all food, and there was * Reported by Mr. John Nicholson, Clinical Clerk. 602 DISEASES OF THE CIRCULATORY SYSTEM. delirium at night. 21th.—Coma, and passage of evacuations involuntarily. On the 28th diarrhoea, sinking. Died on the 29th at 7 a. m. Sectio Cadaveris.—Six hours after death. Head.—Two small patches of yellow purulent-looking exudation were found over the posterior part of the right hemisphere. The lateral ventricles contained about 2 oz. of fluid, clear at the top, turbid lower down, and purulent below. There was no softening of the septum lucidum or central parts of the brain. The subarachnoid space at the base of the brain was infiltrated with purulent matter, as far back as the upper part of the medulla oblongata. Thorax.—The heart was of natural size. The aortic valves slightly incompetent. When the aorta was laid open, a pouch the size of a field-bean, of a purple-red color projected from the left semilunar valve. The most prominent portion of this pouch was very delicate, apparently composed only of an expansion and prolongation of the endocardial covering of the valve—its other textures having been lacerated. The superior half of the upper lobe of the right lung was condensed, and when cut into exhibited the red, passing into the grey hepatization. Many of the granulations were unusually coarse, presenting small collections of pus. The left lung was healthy. Abdomen.—With the exception of a few simple cysts in the ovaries, the abdominal organs were healthy. Commentary.—Though, as a pathologist, I have seen several exam- ples of aneurism of an aortic valve, this is the only one in which the physical signs have been noted. It must, from its appearance, have been of recent formation, and there is every reason to believe that its forma- tion was coincident with the blowing murmur heard over the heart on the 22d of May. This murmur was single, synchronous with the systole, and was probably caused by the impediment offered to the blood when rushing through the aortic orifice. Although there was slight incompe- tency of the valves observed after death, when water was poured into them from above, this could not have occurred during life. The pouch- like formation of the valve still permitted it to perform its function, and there was no murmur with the second sound. The preparation is pre- served in the University Museum, although, from the delicacy of the tissue which formed the aneurism—all the coats of the valve having given way except the endocardium—it has been ruptured, and now presents an aperture of about half an inch in diameter. This rupture must soon have occurred during the progress of the case had life been prolonged. The meningitis following pneumonia is similar to the case of Murray (p. 367), and like it shows the lung to be purulent, although the exudation was disappearing—a fact the importance of which will be referred to under the head of Pneumonia. Case CXVIII.*—Aneurism of the Ascendiny Arch of the Aorta—Incompe- tency of Aortic Valves—Hypertrophy of Left Ventricle. History.—Charles Watt, a3t. 31, groom—admitted June 19, 1850. During the last eight months has frequently had occasion to lift heavy weights, and has occasion- ally felt slight pain in the epigastrium. This suddenly became very violent on the 8th of June; and the next day on walking, he exhibited violent dyspnoea. On the 11th he was cupped, with considerable relief. Has been aware of a pulsation in the neck for two years, but never suffered any inconvenience from it. No dysphagia. Symptoms on Admission.—The cardiac dulness extends three inches transversely. The apex beats with great force between the fifth and sixth ribs, two inches below, and a little to the left of the nipple. A bellows murmur is heard with the second * Reported by Mr. David Christison, Clinical Clerk. ANEURISM. 603 sound, loudest at the base. The first sound is normal. In the right side of the neck, immediately above the sternum and clavicle, there is a pulsating tumor the size of a hen's egg, extending laterally two inches. It communicates a strong impulse and a peculiar thrill to the hand placed on it, and over it there may be heard a loud hoarse bellow3 murmur, synchronous with the impulse of the heart, and this murmur may be heard at the back, extending down the course of the aorta. Pulse 74, regular, hard, and jerking, alternating with the impulse at the apex, stronger in the right than the left wrist. Pain in the epigastrium, and dyspnoea on exertion. No other pulmonary symptoms. Frequent pain in the left temple, extending down that side of the nose. Giddiness on rising suddenly. Frequent musca? volitantes. Progress of the Case.—Continued to have pain in the epigastrium, and dyspnoea at intervals. He was treated by occasional small topical bleedings, which always relieved the symptoms. Blisters also were now and then applied, and latterly small doses of aconite given. The physical signs underwent no change, but the distressing concomitant symptoms nearly disappeared, and he felt so well that he was dismissed, at his own desire, July 15. Commentary.—In this case aortic incompetency was proved to exist by the same sign as we have seen to accompany it in former cases. The visible swelling, diffuse pulsation, and bellows murmur, synchronous with the dilatation of the vessel, could leave little doubt that an aneurism of the aorta existed. It became a question, however, whether the innomi- nata was or was not involved; and I am inclined to consider not, from a variety of circumstances, but more especially—1st, Because the pulse at the right wrist was stronger than at the left; 2d, Because the pain in the head and face was on the left, and not on the right side ; and, 3d, Be- cause the bellows murmur over the tumor was superficial, anterior, and propagated down the back in the course of the aorta. In addition, it could be argued that there was neither dysphagia nor dyspnoea, while the respiratory murmurs were equally loud in both lungs. Now aneu- risms of the transverse arch of the aorta press against the most convex part of the trachea, which is least liable to compression, whilst the oesophagus at this point is well protected. Hence the seat of the aneu- rism explains why deglutition and respiration were not interfered with. Case CXIXft—Aneurism of Ascendiny Aorta immediately above the Aortic Valves—Incompetency of Aortic and Mitral Valves—Hypertrophy of Left Ventricle—Waxy Kidneys—Pidmonary Hemorrhage.—Anasarca. History.—Kenneth M'Kenzie, aet. 5"2, quarryman—admitted October 31st, 1853. Has been more or less subject to rheumatism during the last twelve years. Nine months ago, after much exposure to cold and wet, he complained of unusual palpita- tion and dyspnoea, and has since been subject to paroxysms of breathlessness, suffo- cation, and a feeling of extreme anxiety, unattended with cough or expectoration. Three weeks ago a mass of earth and loose stones fell upon his back between the shoulders, and since then his whole body has been painful and stiff, and the other symptoms much aggravated. Symptoms on Admission.—The impulse of heart is diffuse, raising more espe- cially the fifth and sixth intercostal spaces. The apex beats strongly between the fifth and sixth ribs, in a vertical line below the left nipple. The transverse cardiac dulness begins at the margin of the sternum, and extends three inches and a quarter outwards. On auscultation a loud, harsh, but somewhat musical murmur, is heard at the apex with the first sound, immediately followed by the second sound, which is rather sharp and rough, but without murmur. At the base there is a blowin"- murmur with both sounds, which are particularly marked over the articulation of the fourth rib with the sternum. Over the great vessels at the root of the neck, a * Reported by Mr. William Calder and Mr. Almeric Seymour, Clinical Clerks. G04 DISEASES OF THE CIRCULATORY SYSTEM. single blowing munnur is heard synchronous with the pulse at the wrist, and this is heard loudest immediately above the sternal end of the clavicle. At this point a dis- tinct impulse may be felt with the finger, and even seen by the eye, but no circum- scribed swelling can be made out. A similar impulse and murmur exists above the left clavicle, but not so distinct. Pulse 90, strong, and rather jerking. Has frequent palpitation and dyspnoea, sometimes coming on when lying quite still, and always on making any unusual exertion. Percussion over the lungs everywhere good. On the right side, harsh inspiration both anteriorly and posteriorly. Has a copious expecto- ration of frothy mucus. Breathing somewhat labored and wheezing. The appetite is not good, but the digestive system is otherwise normal. Has occasional headache7 and a frequent feeling of dizziness, with muscae volitantes. Palpitation and dyspncea, when severe, often occasion faintness. Other functions normal. Progress op the Case.—During the month of November there was little change in his condition, although the symptoms were somewhat alleviated by quietude and treatment. December 8th.—Last night was seized with pains in the right chest, accom- panied with great difficulty of breathing. To-day, on auscultation, crepitating rale is mingled with harsh inspiration, and sibilant and sonorous rhonchi on expiration. Per- cussion and vocal resonance good. No rigor or fever. Dec. 22d.—Since last report, the attacks of dyspnoea have become more urgent, and now he cannot assume the recumbent posture. Expectoration is copious and slightly tinged with blood. On the 13th oedema of the ankles made its appearance, and on examining the urine, it was found to be highly albuminous. Pulse 60, jerking. Dec. 29th.—CEdema of inferior extremities has now extended to the thighs and scrotum, and is rapidly increasing. Amount of urine passed daily much diminished, and highly albuminous. Orthopnoea at night, and great dyspnoea at all times. Sputum largely mixed with blood. Dulness on percussion over lower third of right lung posteriorly. January 4th.—Since last re- port there has been general anasarca, with great distension of the inferior extremities and scrotum. Has been unable to assume the recumbent posture, and been obliged to pass the night leaning forward on a table. The urine has continued very scanty, and the pulse, though still jerking, has gradually become weak. He gradually became ex- hausted, and died Jan. 9th, at 11 a.m. The treatment consisted at first of abstraction of small quantities of blood from over the heart or lungs, by cupping or leeches, which always produced temporary relief. Expectorants and anodynes to relieve cough, favor expectoration, and promote sleep. Antispasmodics to diminish dyspnoea. When the dropsy appeared, diuretics and afterwards hydragogue cathartics caused relief, and for a time diminished the accumulation of the fluid. Sectio Cadaveris.—Twenty-five hours after death. Head.—Considerable effusion in subarachnoid cavity. Lateral ventricles contained 3 iij of clear serum. Brain otherwise healthy. Thorax.—Heart much enlarged, weighing 28 ounces. This was owing almost entirely to hypertrophy of the left ventricle, its cavity being dilated and walls much thickened. The aortic valves were shortened, thickened, and incompetent. The mar- gins of mitral valve were thickened, and the chordse tendineae shortened and thickened. The lining membrane of the aorta was rough and irregular from atheromatous and cal- careous degeneration. Immediately above the sigmoid valve, which is next the right venjdcle, was an aneurismal pouch the size of a walnut. It contained no coagula, was formed by a dilatation of all the aortic coats, and its internal surface was rough from atheromatous degeneration. The entire arch of the aorta was also rough from a similar cause, but the descending aorta was normal. Both lungs were oedematous. In the right lung were several masses of coagulated extravasated blood, generally about the size of a walnut. Abdomen.—The kidneys presented the waxy degeneration. Other abdominal organs healthy. Commentary.—This case is an example of a commencing aneurism at the root of the aorta, although it, like the last, may be regarded essen- tially as a cardiac disease, as the physical signs indicated both mitral and aortic incompetency. It was the loud, single blowing, synchronous with the systole, combined with the distinct impulse felt and seen over the clavicle, which pointed to an aortic aneurism. The size of this aneurism could not be large, as percussion failed to detect any dulness ANEURISM. 605 over the chest; and although he at first said that deglutition had been slightly impaired, this symptom was afterward ascertained not to be present. The aneurism may have assisted in producing the incompetency of the aortic valves, which, with the aneurism itself, was occasioned by the chronic arteritis, and subsequent atheromatous degeneration of the arch of the aorta. At what time the mitral disease commenced was un- known, but it was comparatively subordinate to the aortic disease, and was followed by hypertrophy of the left ventricle, and the pulmonary complication. The renal lesion came on when he was in the ward, and we need not be surprised at the universal and rapid anasarca which, under such circumstances, proved fatal. Treatment under such circum- stances could only be palliative. Case CXX.*—Aneurism of Ascending Arch of Aorta—Chronic Peri- carditis—Disease of Aortic Valves—Great Hypertrophy of Heart —Anasarca. History.—Robert Laing, aet. 53, married, a bookbinder—admitted January 11th, 1854. States that he never had rheumatism, and cannot account in any way for his illness, which he dates from about four months ago; previously to that time he was in the enjoyment of excellent health. Palpitation and dyspnoea were the first symp- toms he noticed, and a strong pulsation in the back was observed by his wife. CEdema of the lower limbs came on about a month afterwards, and has since gradually in- creased. During his illness he was treated with diuretic remedies, which produced temporary diminution Qf the dropsy. A few days before admission, the dyspnoea be- came very urgent, but was somewhat relieved by venesection to the amount of a few ounces. Symptoms on Admission.—The impulse of the heart is weak and diffused over con- siderable part of the fifth intercostal space, being felt most distinctly in a line perpen- dicularly below the nipple. Dulness on percussion extends from the left nipple across the chest, nearly as far as the right nipple ; upwards on the left side it extends as far as to the third intercostal space, but above that line percussion is normal. On the right side, dulness extends from apex to base, over a space bounded by the sternum within, and a line drawn vertically through the nipple externally. The heart sounds are much obscured by pulmonary rales ; in the usual situation they are feeble, and their precise character cannot be determined. Over the upper two-thirds of the right side of the chest, as far out as the nipple, there is very loud hoarse double murmur; no impulse can be felt in that region. Pulse 76, and of jerking aortic character; reg- ular, and of equal strength on both sides. Posteriorly the chest is resonant every- where, and loud, sonorous, and sibilant rales are heard; expiration is considerably prolonged. Dyspnoea considerable; there is some cough with frothy mucous expec- toration. The inferior extremities and scrotum are enormously distended, and pit on pressure; the abdomen is swollen, and fluctuation can be detected; the face is pale and somewhat sallow. Appetite much impaired ; thirst considerable. He can lie only on his back or his right side. Has considerable difficulty in speakino-. Urine very scanty and muddy in appearance. Progress of the Case.—January 11th to 13th.—Was treated with antispasmodics and hydragogue cathartics, and afterwards with leeches to the prascordia, which last pleasure relieved the dyspnoea considerably. On the morning of the 13th, on awaken- ing, he called the nurse; immediately afterwards he fell into a state of stupor from which he could not be roused. His pulse was 120, weak ; the pupils were strongly contracted. Brandy and carbonate of ammonia were administered, but he continued in the same state for two hours, and then died. Sectio Cadaveris.—Twenty-seven hours after death. Great anasarca of the body. Thorax.—The veins of the neck greatly engorged, so that on cutting them across a large quantity of black fluid blood escaped. On removing the sternum the * Reported by Mr. Robert Bird, Clinical Clerk! 600 DISEASES OF THE CIRCULATORY SYSTEM. pericardium was seen to extend in a transverse direction from nipple to nipple, so as to measure eight inches across. On being opened, it was found to contain two ounces of serum. Over the anterior and posterior pericardial surface of all the cavities, but especially the anterior surface of the right ventricle, masses of old lymph were attached —in some places smooth, in others rough and shaggy. The heart was enormously en- larged ; the cavities of both ventricles, but especially of the right, were increased in size. Their walls also and the septum were much thicker than natural. The aortic valves were thickened, and could not be applied against the walls of the aorta in con- sequence of masses of calcareous matter deposited at their bases. The whole internal surface of the aorta was rough and thickened by atheromatous degeneration. Imme- diately above the semilunar valves was an aneurismal pouch, springing from the aorta. The opening into it was rather larger than a crown-piece, and was perfectly round. Above this aneurism, formed by a dilatation of all the coats of the vessel, was another, formed only of the middle and external coats. Into this there were two openings— one above the size of a shilling, the other a fourth of that size. This second pouch was partly filled by coagulated blood. Externally, the aneurism was applied immedi- ately over the right auricle, was of a flattened oval form, and about the size of a cocoa- nut. The mitral valve, and those on the right side of the heart, were healthy. The pleurae on the left side were thickened and universally adherent. At the lower part of upper lobe it was of cartilaginous consistence, over a space the size of a crown-piece. The lung was slightly emphysematous at its anterior margin. Bronchi contained mucopurulent matter. The right lung was not adherent anywhere. At the apex were numerous emphysematous bulke the size of peas. Inferiorly and posteriorly, the pul- monary tissue was collapsed in several places. Abdomen.—The liver and kidneys were considerably congested ; otherwise healthy. Other organs natural. Commentary.—In this case the aneurism originating from the ascend- ing portion of the aortic arch was the size of a cocoa-nut, and was formed on the right side. During the life of the patient it was supposed to be much larger in consequence of the extended dulness, which was afterwards determined to be partly dependent on the dilated pericardium. The chronic pericarditis gave rise to no symptoms, but probably assisted in causing the heart's sounds to be obscured, which, however, were sufficiently masked by the bronchitic rales. The loud double murmur heard on the right of the sternum was most probably owing to the flux and reflux of the blood into the first aneurismal pouch; for although similar sounds might have origin- ated from the diseased aortic orifice, they would be rendered inaudible by the pericarditis and bronchitis. The complications here were formidable, and the man died rather from the heart disorder than from the aneurism. Case CXXL*—Large Aneurism of the Ascending Arch of the Aorta, causing Absorption of a portion of the Third Rib, and bursting into the Pericardium—Chronic Pericarditis—Incompetency of Aortic Valves—Hypertrophy of Left Ventricle. History.—James M'Killop, aet. 24, laborer, of intemperate habits—admitted Janu- ary 12th, 1857. He says that two years and a half ago, while engaged in lifting a heavy weight, he suddenly felt something give way in the region of the left chest. From that period he became subject to a beating in that locality, but suffered no other inconven- ience till about four months ago, when he experienced a numbness down the left arm. For the last twelve months he has observed his left chest to be somewhat swollen. Six weeks ago he first felt dyspnoea, which was increased on exertion, and was attended with frequent cough. Two weeks afterwards, he observed his face and neck begin to swell, and this has gradually gone on until now. Continued to work till six weeks ago. Symptoms on Admission.—Apex of heart beats between the fifth and sixth ribs, in- ternal to and below the left nipple. It is feeble and diffused. A heaving pulsation is also felt over the upper part of the left chest, synchronous with the cardiac impulse, * Reported by Mr. H. N. Maclaurin, Clinical Clerk. ANEURISM. 607 having also an expansive lateral motion. On percussion, at a level with the nipple, cardiac transverse dulness is three inches. Above this there is a dull space, bounded by a curved line, which passes internally to mid-sternum, superiorly to the lower bor- der of the first rib, and externally as far as a line passing vertically through the left nipple. This space measures four inches from above downwards, and five inches transversely. It bulges forwards visibly more than the corresponding part on the opposite side, especially in the second intercostal space, two and a half inches from the sternum. On auscultation at the heart's apex, a double blowing murmur is audi- ble, which, however, evidently originates at the base, where it is loudest, the first murmur being rough, and the second comparatively soft. All over the region of the pulsating tumor there is a double murmur, the first not so loud as the second. They are most distinct towards the outer margin of the dull space formerly described, espe- cially at a point one inch above the left nipple. Over both clavicles there is a single rough blowing murmur. Posteriorly, no comparative dulness can be made out on per- cussion. On applying the hand at the base of both lungs, fremitus is perceptible with the inspiratory acts, most marked in the left side. On auscultation, a double murmur is audible all over the left back, loudest between the vertebrae and the edge of scapula. Radial pulse 108, small but strong, without any difference in the two wrists. Both external jugular veins are somewhat distended, so that the position of the valves may be readily perceived. On auscultation over both lungs, harsh sonorous rales are audi- ble, with occasional moist sounds. Expiration much prolonged. Has tickling in the larynx; occasional cough of a hard and somewhat clanging character; expectoration is mucous, not copious; considerable dyspnoea, especially on exertion, and pain in the left chest and shoulder, with numbness in left arm ; sleep is disturbed ; irides normal; strength diminished; considerable oedema of face, neck, and chest only; eyelids puffy; skin hot; appetite good; deglutition unaffected. Digestive, urinary, and other func- tions normal. Eight leeches to be applied over tumor in left chest, and to take a table- spoonful every two hours of the following mixture:— R Sp. JEther. Sulph.; Sp. Ammon. Aromat. aa 3j; Tr. Card. comp. 3 iij ; Aquam ad § iij. M. Progress op the Case.—January 11th.—Little benefit followed the application of the leeches. Yesterday §v of blood were removed by cupping, and caused great relief. ffidema of the face lessened. Jan. 22d.—Complains of pain passing from tumor to middle of left back. Venesectio ad § x. Jan. 24th.— § xj of blood were taken from the arm, causing instantaneous relief from the pain and tingling in the arm. The re- lief continued till to-day, when the pain has returned. Pulse 100, sharp. Other symp- toms the same. Morphia and Ether draught. Jan. 29th.—Pain continues. Dyspnoea and cough have increased. Face and neck again very oedematous. To be cupped over left breast, and f vj of blood taken. Feb. 2d.—Was again greatly relieved by the cupping. Complains of tickling in the larynx. The tumor has extended some- what upwards, and its pulsation is distinctly felt at the right border of the sternum opposite the second rib. R- Tinct. Lobeliw Inflates 3 ij; Sol. Mar. Morph. 3 j ; Aquam ad 3 vj. M. One table-spoonful three times in the night. Expired suddenly at 7 p.m. on the 8th, the symptoms having undergone little change. Sectio Cadaveris.— Thirty-two hours after death. Body not emaciated. Left side of thorax rather fuller than right. Thorax.—There was some oedema of the parietes, greater upon the left than the right side. On reflecting the soft parts, there was an evident prominence in the left mammary region, rounded in form, and about two and a half inches in diameter. The pericardium was much distended, and contained twenty ounces of blood. An aneurism arose from that portion of the ascending aorta contained within the pericardium, com- mencing immediately above the semilunar valves and the origin of the coronary arte- ries. The aorta below this point was not dilated. The aneurism anteriorly appeared to be divided into two lobes; the left, much larger than the right, and of the size of a large cocoa-nut, passed upwards and forwards, its long diameter being nearly parallel to the anterior wall of the thorax, to which the greater part of its surface was adherent; the right, larger than a turkey's egg, passed backwards and a little downwards, its long diameter being nearly parallel to the base of the thorax. The anterior extremity of the right lobe did not approach within two inches of the thoracic wall. Posteriorly no such division into lobes could be seen, but merely a single large aneurismal sac divided into two compartments by the aorta. The left pouch was found adherent to the poste- rior surface of the sternum, between the junctions of the second and fourth ribs, and 608 DISEASES OF THE CIRCULATORY SYSTEM. to the cartilages and part of the bodies of second, third, and fourth ribs. Over this space, measuring about six inches across, and nearly four vertically, the sac could not be separated from the thoracic parietes; on the contrary, the finger introduced into the sac detected rough exposed bone in various situations, corresponding to the promi- nence observed. Externally there was a gap in the thoracic wall, formed by the absorption of a considerable portion of the third rib, external to its junction with its cartilage. The recurrent nerves were displaced and stretched, especially the left, in consequence of the transverse portion of the arch of the aorta being pushed backwards. A rupture of the aneurism into the pericardium had taken place at the most dependent part of the larger sac, at a point corresponding to the right margin of the sternum be- tween the junction of the fifth and sixth right costal cartilages with the sternum, but about two inches behind it. The orifice was of a linear form, half an inch in length and immediately overhanging the right auricle. The sac contained chiefly loose clots but some imperfect layers of decolorised tough fibrin were in some places adherent to its walls. The heart was displaced downwards and backwards. The larger sac inter- vened between it and the thoracic walls, so that its base was on a level with the lower margin of the fourth rib, and five inches behind it. The heart was hypertrophied, but, as it was kept attached to the preparation, it could not be weighed. The hypertrophy was most marked in the left ventricle. The surface of the heart was roughened by shaggy growths of old plastic lymph, most abundant over the left ventricle. Pericar- dium not adherent. The aortic valves were evidently incompetent, being opaque, thickened, and shortened. There was a small aneurism of this portion of the arch, between the origin of the innominate and left carotid arteries, and partially involving the commencement of each of these vessels. It was about the size of a large filbert. The lining membrane of the thoracic and abdominal aorta was but slightly atheroma- tous. The larynx was quite natural. The right bronchus was compressed at the point of adhesion between the lung and the smaller sac. The substance of the lungs was quite natural. The right pleura contained a pint and a half of clear serum. Abdomen.—Abdominal organs healthy. Commentary.—In this case, the aneurismal tumor developed itself on the left side, and caused a visible swelling with protrusion in the left chest. It was of larger size, and of older growth than in the previous cases, and by constant pressure forwards on the ribs had occasioned caries and interstitial absorption of the bones. In consequence of press- ure posteriorly on the bronchus, and recurrent nerve, it occasioned harsh cough and tickling of the larynx. Although here also the aortic valves were incompetent, the sounds were marked by a loud double blowing murmur, evidently connected with the aneurism, because they were audible in the left back. Only one sound, however, could be heard at the root of the neck above the clavicles, owing to a dilatation of the aorta between the innominate and left carotid arteries. In this, as in Case CXX. a chronic pericarditis existed, which was not indicated by any symptoms. The relief to symptoms by small abstractions of blood was particularly well marked, although it is perhaps almost unnecessary to say that the real disease was in no way altered, and continued its march towards a fatal termination. (For a case of thoracic aneurism bursting into the pleura see Case LXX1X.) Case CXXIL*—Varicose Aneurism of the ascending Aorta communi- cating with the Pulmonary Artery—Jaundice and Nutmeg Liver. History.—Alexander Calder, aet. 33, a teacher—admitted June 11th, 1855. He had always enjoyed good health until the beginning of last February, when he felt a pain under the ensiform cartilage, which felt like the pricking of a pin, and continued for a week. About a fortnight after this, while walking hastily, he felt as if some- thing had given way below the ensiform cartilage, which caused him to slacken his pace, and produced a sensation of weakness. He continued to feel weak for a fort- * Reported by Mr. Robert Byers, Clinical Clerk. ANEURISM. 609 night, and then resumed his duties, though far from well. During the next two months he occasionally expectorated a little blood, and experienced cardiac palpitation. Two months ago he lost blood at stool (6 or 8 ounces passing at a time during three d,ays), which was regarded as dysenteric. He has long been subject to hemorrhoids. Last April his feet began to swell, and the abdomen to enlarge, symptoms which have con- tinued more or less since. Latterly the palpitation has increased, and there has been considerable dyspnoea and cough, with occasional vomiting. Symptoms on Admission.—On percussion, the transverse dulness of the heart measures three inches. Its impulse is diffused, strong, and irregular. On ausculta- tion, a soft blowing murmur is heard over the apex with the first sound, and the second sound is distant but healthy. At the junction of the third costal cartilage with the sternum, the first sound is loud, prolonged, and blowing; the second is short, abrupt, and rasping. Over the manubrium of the sternum there is a rough continuous blow- ing murmur, occupying the period of both sounds. The same murmur is audible under both clavicles anu to the right of the manubrium, but is there softer and more distant. Pulse 90, irregular, but of natural strength. He has considerable dyspnoea on going up stair3, and a trifling cough. Over the anterior surface of chest the respiratory murmurs are harsh, but otherwise percussion and auscultation furnish no signs of pulmonary disease. Pressure over the stomach is painful. Tongue clean; vomits once or twice a day after coughing. Abdomen rather tumid, but percussion and pal- pation discover nothing abnormal. The feet, legs, and thighs, are oedematous, pitting strongly on pressure. Urine small in quantity and high in color. It contains a super- abundance of lithates, but no albumen. Sp. gr. 1025. The other functions are well performed. He has taken a variety of remedies; at one time drastic purgatives, and at another the strongest diuretics, all of which have only produced temporary relief. Q Sp. JElher. Nit. 3 ij ; Tinct. Hyoscyami 3 ij ; Liq. Ammon. Acetat. § ij ; Aqum 3 vj. M. Habeat. § j ter die. Progress of the Case.—June 16th.—The rest and quietude he now enjoys have apparently benefited him, but he sleeps little. R Sp. uEther Sulph. min. xv; Sol. JIur. Morph. min. xx. Ft. haustus. To be taken at bed-time. June 19th.—The breathing is more embarrassed, and the mdema of the lower extremities increased. The cough also is more severe, and he has vomited every meal. Pulse 100, weak. 5 Sp. jEther. Nit. 3 j; Sol. Mur. Morph. 3 j ; Mist. Camphorm § jss. M. Half to be taken at 5 p.m., the rest at bed-time. June 21st.—Since last report the skin has gradually become jaundiced, and the features are now shrunk and anxious, pulse 128, weak. Vomiting was checked by the medicine ordered, but he is unable to take food, or stimulants. R Ammon. Carb. gr. v; Tinct. Card. Comp. 3 ij; Mist. Camph. 3 iss; half to be taken immediately, and the other half in an hour. June 22d.—Con- tinues to sink, notwithstanding the liberal administration of stimulants and nutrients. Died at half-past two on the morning of June 23d. Sectio Cadaveris.—Thirty-four hours after death. External Appearances.—The general surface and conjunctivae of a yellow tinge —lower extremities oedematous; and several phlyctenae, filled with sanguinolent serum, existed on the trunk and upper part of the thighs. Thorax.—The pericardium was natural ; it contained § ss dark-colored serum. On removing the heart a bulging was observed between the aorta and pulmonary artery. Seen externally it appeared to rise from the latter vessel. It was of a rounded, rather flattened form, somewhat smaller than a chestnut; when, however, the finger was passed down the aorta it entered this bulging, which proved to be an aneurismal sac, rising from the root of the aorta. A stream of water passed down the aorta escaped rapidly at first; but the latter portion was retained by the semilunar valves, which proved competent. On laying open the aorta, the aneurism was found to commence immediately above the semilunar valves. Its opening into the vessel was circular, and rather smaller than a florin. The sac itself was of an irregularly rounded form, its greatest diameter (from above downwards) being two inches. Its capacity about that of a large walnut. The sac was empty, and contained no trace of a clot. At the apex of the tumor was found an opening, which passed into the pulmonary artery. (The sac, as already mentioned, was closely applied to this vessel.) When the pulmonary artery was cut open, the com- munication became more distinct. This opening was about four lines in length, and the lips a line and a half apart, so that it was oval in form, with its margin slightly rounded off. It was situated transversely to the length of the pulmonary 39 610 DISEASES OF THE CIRCULATORY SYSTEM. artery, and was rather more than an inch higher up than the point of union of two of the pulmonary semilunar valves. The whole of the cardiac valves were natural. Thejeft ventricle was rather more capacious than usual; its walls were of the normal thickness. The right ventricle was also a little dilated; its walls were more decidedly hypertrophied. The heart weighed 15^- ounces. On section of both lungs, they were seen to contain several diffused patches of extravasated blood, recent and confined to the air cells. Abdomen.—In the cavity of the abdomen was about a pint of turbid serum. The liver when cut into exhibited congestion of the portal capillaries, causing the so-called nutmeg appearance. The spleen, kidneys, and other abdominal organs, were healthy. Commentary.—Cases of aneurism communicating with the pulmonary artery are very rare, and the physical signs to which they give rise have, as far as I can discover, only been recorded in three other instances. Of five cases collected by Mr. Thurnam,* there is only one in which the sounds were accurately observed. It was published by Dr. Hope,t and was communicated to him by Dr. David Monro of Edinburgh. In that case the size of the aneurism is not given; it is vaguely called " large," but it " communicated by two openings with the pulmonary artery, the larger capable of receiving the point of the little finger, the smaller of transmitting a crow's quill. The edges of both were regular, round, and cartilaginous. Nearer the arch, a third small opening was discovered, with thin rugged edges." "All the valves were healthy, excepting the semilunar at the mouth of the aorta, which was thickened." We are not informed to what extent the aortic valves were thickened, and whether such thickening produced incompetence in their action. But we are told that " the first sound was accompanied by a loud blowing murmur, most distinct at the middle of the sternum, but audible over the whole fore- part of the chest, and over the back on both sides of the spine. The sec- ond sound was short, and much obscured by the first." This account renders it probable that the murmur was synchronous with the ventricu- lar contraction, was caused by the rushing of blood through the laceration of the aneurism into the pulmonary artery, and was not owing to the valvular disease. In a case of Professor Smith's of Dublin,;): the pul- monary artery communicated with the aorta by a small opening at the origin of the latter vessel. The edges of this opening were thickened and rounded off. There was dilatation of the aorta at the point of opening, with distinct signs of arteritis. The auriculo-ventricular openings were healthy. A loud blowing murmur accompanied the first sound, and an in- tense purring tremor could be felt over the whole cardiac region. Where this blowing murmur was heard loudest is not stated, and we are at a loss to determine whether it was owing to the wave of blood rushing through the dilated and roughened aorta, or its passing through the orifice into the pulmonary artery. Of the second sound nothing is said The purring tremor may have been occasioned by the rapid gush of blood through the small opening of the aneurism, and a similar tremor was observed by Mr. Thurnam, Dr. Williams, and Dr. Hope, in a case where an aortic aneurism communicated with the right ventricle of the heart, by two small rounded apertures. That such tremor should occur where the opening is large, appears to me improbable. * Medico-Chir. Trans., vol. xxiii. p. 349 et seq. | Diseases of the Heart, 3d edit. p. 469. % Dublin Journal of Medical Science, vol. xviii. p. 164; and Stokes on the Dis- eases of the Heart and Aorta, p. 554. ANEURISM. 611 In the present state of our knowledge as to the signs which accom- pany an aortic varicose aneurism communicating with the pulmonary artery, the case of Calder appears to me to be of, great value, as the physical signs were examined with great care, and recorded at my dicta- tion by the clerk at the bed-side. At the time they were exceedingly puzzling, because the idea suggested by the double sound heard at the base of the heart—whieh, under ordinary circumstances, would have indicated aortic disease with stricture—was negatived by the fact that the second sound was distinctly audible at the apex clear and healthy. At the same time, the manner in which the disease occurred, the ana- sarca indicating impeded circulation, the dyspncea and irregularity of pulse gave evidence of a profound lesion of the heart, although its nature was very mysterious, the more so as no thrill or tremor could be detected. The case, however, was at once made clear, and the nature of the sounds explained, by the examination of the body after death. All the valves were healthy, and hence the double sound must have been entirely owing to the flux and reflux of blood through the communication between the aneurism and pulmonary artery. The murmurs were heard loudest over the seat of the communication, below the junction of the third left costal cartilage with the sternum ; became continuous as they were propagated upwards; but inferiorly at the apex of the heart, only the systolic blowing was audible, together with the natural sound of the semilunar valves. The size of the laceration or connecting opening explains the absence of whiz and tremor. These facts appear to mc very valuable as distinctive of such a lesion when the valves are healthy. If, as frequently happens, they are diseased, there must always exist excessive difficulty, if not an impossibility, of ever dis- tinguishing such a form of aneurism in the living subject. Mr. Thur- nam, in his excellent paper, appears to me rather too sanguine on this point. The other phenomena presented by the case are at once explained, by reflecting on what is likely to happen by a considerable quantity of blood being propelled from the aorta through a large opening into the pulmonary artery, and thus sent to the lungs again without having passed through the systemic circulation. As stated by Mr. Thurnam, the effects are referable to one or more of three circumstances :—1st, Loss of blood to the systemic circulation, and as a result, feeble, occa- sionally jerking pulse, debility, tendency to syncope, and diminution of animal heat. 2d, Impediment of the return of venous blood from the distant veins, and, as a result, venous congestion of the liver, mucous membrane, and extremities, with engorgement and dilatation of the right side of the heart, and as a result, dropsical effusions, and espe- cially anasarca. 3d, Excessive stimulation of the lungs by the recep- tion of arterial instead of purely venous blood, and hence dyspnoea, cough, pulmonary congestion, and extravasation of blood. All these effects were observed in the case we have had before us. A retro- spective view of the facts and phenomena of this and similar cases must impress upon us the truth that drastic purgatives and diuretics, how- ever they may relieve, cannot be expected to produce any permanent benefit. Indeed, whenever general anasarca is evidently dependent on organic disease, it seems to us that the mildest remedies should be 612 DISEASES OF THE CIRCULATORY SYSTEM. employed, especially taking care by their use not to lower the general powers of the constitution, so that life may be prolonged as much as possible. Since the above Commentary was published in the last edition of this work, another case has been accurately observed by Dr. Wade of Birmingham, and diagnosced by him during life. It was read to the Medico-Chirurgical Society of London, June 11, 1861.* A man, aged 35, two weeks before admission to the hospital, made a sudden and violent exertion, producing temporary faintness without marked cardiac symptoms. Physical examination.—Cardiac dulness increased vertically. Apex seen and felt in the sixth intercostal space. Over the cartilage of the left fourth rib a loud murmur replaced both sounds, that with the second being of a hissing character, and so prolonged'as to continue till the commencement of the next first sound. Usual second sound inau- dible there. Marked thrill at this spot coincident with second murmur. First murmur, a loud bruit de soufflet. Both murmurs heard in the carotids and over the upper chest. At the apex, a single murmur with first sound; normal second sound very distinct. No venous distention. Thrill in the carotids, pulsation of which was visible. Mucous rales in back of both lungs. Liver enlarged. From this combination, Dr. Wade concluded—1, That blood escaped either from the aorta or pulmonary artery during their systole ; 2, That it was probably from the aorta that the blood escaped; 3d, That it did not regurgitate into either ventricle ; 4, That it regurgitated into one of the auricles, or else into the pulmonary artery; 5, That it did not regur- gitate into the left auricle; 6, That the opening was into the pulmonary artery, rather than into the right auricle; 7, That the communication was probably due to aneurismal perforation of the aorta, at or near its origin. On the 14th of June he was seized with faintness and violent cardiac perturbation, which continued till the 28th, when he died. The post- mortem examination showed an aneurism of the size of a small hen's egg very near the root of the aorta, with a rounded, smooth, thickened open- ing into the pulmonary artery at its origin, and another, fissured, ragged, evidently recent one into the right ventricle. The valves were all healthy. This case, in conjunction with that of Calder, will serve to establish the physical diagnosis of this rare lesion. In both there were the same signs—viz., a whizzing or lisping murmur replacing both sounds over the aneurism, while the first and second sounds of the heart were heard nor- mal at the apex and at the root of the carotids. Case CXXIII.j-—Aneurism of the Arteria Innominata. History.—Catherine Syme, aet. 56, a sempstress—admitted May 2, 1853. She says that her habits have always been temperate and regular. Fifteen years ago she had an attack of acute articular rheumatism, which afterwards became chronic, and rendered her incapable of working for eighteen months. For six years past she has * Brit. Med. Journal, July 6, 1861. f Reported by Mr. Robert Brown, Clinical Clerk. ANEURISM. 613 been subject to occasional attacks of giddiness and swimming in the head, accom- panied by a loud noise like the clanging of machinery. Fourteen months ago, in the night, she was seized with a fit of intense dyspnoea, threatening suffocation and accompanied with a loud crowing noise on inspiration. The attack lasted about eight minutes. Three months afterwards, she experienced a somewhat similar but milder attack also in the night, during sleep. She now observed that her voice was becoming rough and hoarse; and a few months later, she felt slight difficulty in swallowing, at a point corresponding to the upper border of the sternum. In the early part of January 1853, after unusual exposure to cold, the dyspnoea returned every morning, gradually became urgent, and generally terminated in the expectoration of a small quantity of mucus. There were also palpitations, and she became subject to sudden startings from sleep. A week ago, all these symptoms became so much aggravated, that she was unable to leave her bed. Symptoms on Admission.—The cardiac dulness measures two inches across. The apex beats between the fifth and sixth ribs, a little to the inside of the nipple. Heart's impulse is somewhat diffused, rhythmical, and of good strength. A blowing murmur accompanies both cardiac sounds, that with the first sound being loudest at the apex, and that with the second being loudest at the base. Immediately above and towards the outer side of the right sterno-clavicular articulation, a pulsating tumor, about the size of a hen's egg, is visible to the eye. It is felt beneath the sternal and inner por- tion of the clavicular origins of the sterno-mastoid muscle, presents a distinctly rounded outline, and anteriorly slightly overlaps the trachea immediately above the upper border of the sternum. The impulse is strong and diffused, and a loud, clear, abrupt murmur is heard over it, synchronous with the second sound of the heart. The pulse is regular, 106, of good strength, equal at both wrists. There is a paroxys- mal cough, harsh, prolonged, and of a clanging metallic character, always worst in the morning, when it is accompanied by urgent dyspnoea, and a loud crowing inspiration. Sputum scanty and gelatinous, containing a few flocculi of pus. Voice hoarse and • weak. Chest everywhere resonant on percussion, but not unusually arched. Respira- tory murmurs very faint, but normal in character. Expiration much prolonged. Appetite impaired. When swallowing solid food, she says the bolus seems to meet some obstruction at a point corresponding with the upper border of the manubrium of the sternum. The countenance is anxious, face livid, and the superficial veins of the chest and lower part of the neck are very large and turgid. Sleep restless and easily disturbed. Other functions normal. Progress of the Case.—The symptoms previously noticed continued, with occasional remissions, until the 20th of June. On that day it was observed that the blowing murmur synchronous with the second sound at the base of the heart, was much less distinct, and that the murmur with the first sound at the apex was replaced by one with the second. The veins over the upper part of the chest have been gradually enlarging. On the 6th of July, a careful examination elicited the following results:—Pulse 88, soft, equal in both wrists. The impulse is very strong over the tumor, and on auscultation there are now heard two sounds, the second being loud, abrupt, and exceedingly clear—no blowing audible. These sounds diminish gradually in intensity as the stethoscope approaches the left edge of the manubrium of the sternum, where the two cardiac sounds are heard quite normal. As the instrument descends towards the heart's apex, the second sound gradually assumes a soft blow- ing character, which at the apex is loud and distinct. The first sound is quite normal. Posteriorly above the right scapula, the sounds of the tumor are heard at a distance, but disappear towards the centre of the back, and are inaudible along the vertebrc-1 column. July 8th.—For the last few days the dyspnoea in the morning has been very urgent, and the cough coarser, and of a metallic clanging sound. To-day the paroxysm continued 15 minutes, and even now, at the visit, the breathing is noisy, labored, and hurried, the dyspncea urgent, and the paroxysm of cough severe and at short intervals. She cannot expectorate easily. The voice is feeble, and the countenance expressive of great anxiety. To relieve these symptoms tracheotomy was attempted by Mr. Syme; but, having made two incisions, and cut through the integument and subcutaneous fat, such an amount of venous hemorrhage occurred that he desisted, applied a ligature to the large veins, and declined to perform laryn- gotomy. July 9th.—The loss of blood caused considerable relief, and she passed a tolerable night. A double blowing murmur is now audible both at the apex and base 614 DISEASES OF THE CIRCULATORY SYSTEM. of the heart. That accompanying the second sound is loudest over the apex, while the one accompanying the first is heard loudest over the ensiform cartilage. July 12th. —Last night about half-past eleven p.m., a severe paroxysm of dyspnoea, threatening suffocation, came on. The house-surgeon, Dr. Dobie, enlarged the incision made by Mr. Syme, upwards, and inserted a common-sized tube into the trachea and larynx after dividing the cricoid cartilage. To-day she is again better, the operation having been followed with immediate relief. She still breathes, however, with difficulty through the tube. The countenance is livid and anxious, extremities cold pulse feeble and fluttering, surface bedewed with a clammy sweat. She now gradually sank, and died at half-past eleven p. m., on the 14th, embarrassment of the respiration being apparently increased by the difficulty of expectoration. Immediately before expiring, she ejected through the tube about § j of dark grey-colored foetid pus, of the consistence of thick cream. The treatment throughout the progress of the case was directed to alleviating the cough and expectoration, by means of anodynes and expectorants, and diminishing the paroxysms of dyspnoea by means of diffusible stimuli. Cupping over the sternum, and the occasional application of leeches, were employed, and for some time these remedies undoubtedly caused great relief. The surgeons of the Infirmary were unanimously of opinion that the aneurism did not admit of relief from any operation. Latterly the propriety of tracheotomy or laryngotomy was discussed as a palliative, and ultimately tried with the effect already described. Sectio Cadaveris.—Thirteen hours after death. The edges of the wound through which the larynx had been opened were thick- ened, the surrounding muscles discolored and infiltrated with pus. Thorax.—The heart, aorta, and parts connected with the aneurism, were removed en masse, and carefully dissected, with the following results:—The heart and its valves quite healthy, with the exception of slight thickening of the margin of one aortic valve. The arch of the aorta immediately above the valves considerably dilated, and the whole of its internal surface thickly studded with atheromatous and calcareous plates. The whole arteria innominata dilated into an aneurismal swelling of a round and somewhat flattened form, having a diameter of fully three inches. The trachea is pushed by it towards the left side, as represented in the accompanying figure, in consequence of which the incision that was made in the median fine during the operation, was within one-eighth of an inch of the aneurism. The tumor, by pressing on the right side of the trachea, caused much bulging into and diminution of its calibre. The left innominate vein was nearly obliterated. The remains of its in- terior contained a softened clot resembling pus, which communicated by a small open- ing through the aneurismal sac with a portion of the laminated clot, which occupied about three-fourths of its internal cavity. The opening into the sac from the aorta was about the size of half-a-crown, and presented a sharp circular margin. Posteriorly the nerves were reddened, and for the most part enlarged, and firmly united to the posterior wall of the tumor. The superior laryngeal nerve was healthy, being above the tumor; but the inferior was compressed and imbedded in thickened cellular tissue. The posterior half of right lung was partially covered with recent lymph, not adherent, and the pleural sac contained two or three ounces of sero-purulent fluid. The lower lobe of the right lung was hepatized; and on cutting into it, several abscesses up to the size of a cherry were found. The left lung was oedematous, and its bronchi were filled with muco-purulent matter—otherwise healthy. Abdomen.—The liver presented the incipient waxy appearance. • The spleen was dark in color, and pulpy, almost diffluent in consistence. The kidneys were crowded with minute cysts, and the cortical substance considerably atrophied. Commentary.—This case terminated in the usual way, by pressure on the nerves of respiration, causing dyspnoea, and at length partial latent pneumonia. The double clear sound over the aneurismal tumor I have been in the habit of attributing to the flux and reflux of the blood over a sharp vibrating opening into the tumor. In few aneurisms were these sounds more decidedly present than in the case under consideration, and few ANEURISM. 615 after death presented an opening having the margin in question better formed. In another case of aneurism of the innominate artery (that of John Hunter), examined at the .^ jt... commencement of the winter ses- sion 1856-57, the tumor was very distinct in the neck above the e clavicle, but without sound of any / "~ » ^ kind. It was determined after death that the arteria innominata was dilated to the size of a thumb, n -j. m-fjN..........._____g and gave origin to the aneurism, ° ft :f!/M/.........................-h which was globular and four in- \^ .gf ches in diameter, without any circular margin, but rather by means of a narrow neck, as in Fig. 446. The sounds heard over the heart, however, in the case of m w r* m Catherine Syme, changed their character as the disease advanced. At first, double valvular disease was suspected, but latterly, when the murmurs became reversed, and it was most carefully deter- mined, by repeated examinations, that the murmur at the apex was with the second, and that at the base was with the first, sound, they were attributed to propaga- tion downwards from the aneu- lg' ' ... rismal tumor. I am by no means satisfied, however, that this theory is correct with regard to cardiac murmurs, so distinct as those in the pre- sent case, associated with aneurismal tumors and a healthy heart. I content myself, therefore, for the present, with placing the facts on re- cord, as their accuracy is undoubted, and they were confirmed not only by my own repeated examina- tions, but by those of the clinical class and of the I / clerks, all of whom took great interest in the case. *^J? The question of putting a ligature on the vessel 4 having been decided by the Infirmary surgeons in the fjT~~\ W\ negative, the only other question of treatment was the ' *■ I prolongation of life. The source of danger was evi- Fig. 443. dently°he dyspncea, and the frequent attacks of spas- modic laryngeal obstruction, so common in aneurismal cases from pressure of the tumor on the recurrent nerve. The trachea was also considerably Fi°- 445 Rou^h sketch of the aneurism and adjoining parts; a, opening into the larnyx°- b line of°original incision which inferiorly came close upon the tumor; c, aneurismal tumor; d, point where the obstructed vena innominata had ulcerated into the tumor; e, right carotid; /, right jugular vein; <7,left carotid ; h, left subclavian. Fi» 446 Diagram of an aneurism of the arteria innominata, m which the tumor sprang from the dilated vessel with a narrow neck, and in which no sounds were audible. 616 DISEASES OF THE CIRCULATORY SYSTEM. pressed upon and pushed aside, but this could not have accounted for the paroxysms of suffocating dyspncea, for though diminished in calibre it was still largely open for the admission of air. On the other hand the recurrent nerve was found after death thickened, and embedded in dense cellular tissue immediately behind the tumor. Under such cir- cumstances it has been proposed, by passing a tube into the larynx or trachea, to avert the effects of these spasms. In the present case tracheotomy could not be performed; and whenever the deep-seated venous obstruction is of such a character as to cause enlargement of the superficial veins, laryngotomy is the operation that should be attempted. This at length was accomplished, with momentary relief; but I have no hesitation in saying that the difficulty of expectoration, and the conse- quent clogging of the air-tubes, led to results equally distressing and fatal as the spasmodic attacks. It has, indeed, been said, that in these cases the operation is generally delayed too long, and that by waiting until there is much secretion of mucus and diminution of strength, no very good effects can be reasonably expected. But in cases of aneurism, it is at best only to be considered as a palliative; and considering how very difficult expectoration must always be under such circumstances, I con- sider it very doubtful whether it is ever justifiable except as a dernier resort. Certainly the case now recorded is anything but favorable to the practice. In this case it was observable that after the incisions in the integu- ment were made, without tracheotomy having been performed, great relief was occasioned, which continued upwards of two days. Was this owing to the few ounces of blood lost during the operation, or to the idea which she had adopted that the operation would cause relief? However it may be explained, there can be no doubt that the excessive dyspnoea and other urgent symptoms were alleviated as if by a charm, in conse- quence of the unsuccessful attempts to open the trachea. Case CXXIV.*—Aneurism of Transverse Aortic Arch—Chronic Peri- carditis with effusion— Tubercular Lungs—Anasarca—Former Popli- teal Aneurism cured by compression. History.—George Fairweather, 83t. 32, a laborer—admitted January 20th, 1854. Originally a farrier, he entered the army in 1839, and served twelve years. In 1842, while in India, he was laid up with rheumatic pains. A year ago, while employed in the Edinburgh police force, be was obliged to run a great distance in the discharge of his duty. Shortly afterwards, an aneurism made its appearance in the right popliteal space. Of this he was cured in the Glasgow Infirmary by means of compression. He has since been troubled with cough and pain in the breast, and between the shoulders. Last August he became very hoarse, and entered the Glasgow Infirmary, where he re- mained for two months. Towards the close of that period he noticed that his feet were swollen, and began to suffer from palpitation, with pain in the praecordial region. He was dismissed from the hospital as incurable. The swelling in the ankles now increased, and passed up the legs to the abdomen. On the 1st of December last he returned to the Glasgow Infirmary, and left it three days ago, without having experi- enced any relief. Since then his urine has become much diminished, and yesterday it was entirely suppressed. Symptoms on Admission.—The point where the apex of the heart beats cannot be made out; the cardiac impulse is not felt in its usual position; and the cardiac sounds are inaudible over the region of the apex. At the base of the heart the sounds are quite healthy, and also over the centre of the sternum. The transverse * Reported by Mr. Almeric Seymour, Clinical Clerk. ANEURISM. 617 cardiac dulness is fully four inches. There is an unusual dulness above the left nipple, extending over a space about the size of the palm of the hand; here the normal cardiac sounds are heard. They are also heard, unaltered in character, all over the manubrium of the sternum as high as the first intercostal space. Pulse 66, very weak and irregular, and somewhat stronger in the right wrist than in the left. Over the ri^ht lung percussion is normal; posteriorly there is dulness at the lower two-thirds of the left side. Loud, sonorous, and sibilating rales audible over most of the chest on inspiration and expiration; the latter movement being much prolonged. Cough troublesome, and accompanied with a peculiar crowing sound. Sputum frothy, gelatinous, and tinged with blood. When the cough comes on he has great dyspnoea, and respiration is accompanied by a wheezing laryngeal sound. He cannot lie upon his right side, from a sensation of choking that comes on; he feels easier when in a semi-erect position, or on the left side; dyspnoea is most troublesome at night. Tongue moist and furred; appetite good; has a feeling of oppressive tightness in the epi- gastrium after taking food; hepatic dulness four inches; bowels rather loose. A small quantity of urine has been passed since last night; it deposits a pink sediment, which clears up on being heated; sp. gr. 1022. The whole surface of the body is oedematous; abdomen and SGrotum much distended; face and hands livid, and cold to the touch ; feels cold all over the surface of the body. R Infus. Digitalis § iss; Sp. uEther. Nitric. 3 iij ; Acet. Potassa 3 iss; Aqua? § iv. M. one ounce to be taken three times a day. Progress of the Case.—January 21st to 26^.—Has continued the above mix- ture, and was ordered to apply very strong infusion of digitalis over the abdomen. The anasarca is much diminished, fifty ounces of urine having been passed within the last twenty-four hours. Hands rather cold. Physical signs as before. Pulse 120, of better strength. No difference in the pulse of either wrist. The cough being very troublesome, last night he was ordered a mixture containing Sp. JEiher. Nitric, and Sol. Mur. Morphia;. Considerable dyspnoea after taking solid food. A bedsore has formed on the left gluteal region, from his always lying on that side. R Potassa; Bitart. 3 j quater in die. Jan. 26th to Feb. 1st.—The dropsy has become much less, having entirely left the legs; the size of the abdomen is also diminished; there is more anasarca on the right side of the chest, on which he generally lies, than on the left. On one occasion, the amount of urine passed amounted to 150 ounces in the twenty-four hours. On the 31st he had great pain under the left clavicle, with fric- tion at the base of right lung; six leeches were applied over the painful spot. As the cough is very troublesome, let him take a drachm of Tr. Opii Camph. at bedtime. Continue the digitalis internally, but stop the external application. Feb. 1st to 6th.— Cough has been very troublesome, but has been relieved by opium, Sp. ^Ether. Nit. and chloroform internally. 6th.—The cardiac sounds may be heard, normal in character, over the right side, commencing from the third rib ; the impulse may also be seen and felt in that locality. There is also dulness, which may be observed as high as the top of the sternum, extends in a sloping direction to the third rib, and can be elicited down the whole right side. Feb. 15th.—Almost total dulness and want of expansion over the left side before and behind; nor is any respiration heard except at the apex. Apply a blister (6 by 5) to the middle and inferior part of the left side. Feb. 16th to 25th.—On the 16th had a violent paroxysm of coughing, lasting for tec minutes, and attended with profuse purulent expectoration. Ordered the following:— R Misturce Scillrn § v; Tr. Opii Camph. 3 j. A tablespoonful to be taken when the cough is*urgent. A morphia draught at bedtime. These remedies relieved the cough. The sputum became more frothy and gelatinous. He also slept better. On the 25th, there is almost total dulness over a space nearly three inches in diameter, in the left sterno-clavicular angle, with gradually increasing clearness towards the outer sub- clavian space. There is no respiration in the former region, and moderate natural respiration in the latter. Over the rest of the left side, in front and laterally, percus- sion is very dull, and respiration all but absent. There is general dulness, and very faeble respiration in the upper half of the left back, with prolonged sibilation after coughing; respiration is bronchial and feeble in the lower half. On the right side, percussion is clear, with puerile respiration, both before and behind, except for about three inches to the right of the upper sternum, where percussion is somewhat dull. He has still occasionally a difficult and copious expectoration of a tough mucous matter. Cardiac sounds natural, except a very slight tendency to reduplication of the second. Feb. 25th to March 4th.—Continued in much the same state till the evening of March 3d, when another fit of coughing and dyspnoea came on. Sulphuric ether, 618 DISEASES OF THE CIRCULATORY SYSTEM. and others of the medicines mentioned above, were administered. He sank, however, and died at half-past 11 a.m., March 4th. Sectio Cadaveris.—Forty-eiyht hours after death. Thorax.—The pericardium was much distended, and contained 12 oz. of clear serum. Its lining membrane was very hard in some places, from the presence of chronic lymph. The heart and its valves were healthy. Between the arteria inno- minata and the left carotid was a small dilatation of the arch. Immediately below the origin of the left subclavian, an aneurism, the size of a large orange, of rounded form, and three inches in diameter, originated from the aorta by a thick neck. It pressed forward and to the left side, immediately above the pericardium, sh'o-htly com- pressing the trachea and left bronchus. The recurrent nerve was seen to pass in front of the aneurism uninjured. On examination of the aneurism, it was found that the internal and middle coats of the aorta had given way, the pouch being formed of the outer coat, and of condensed areolar tissue. Above the aortic valves, and over the arch, the inner layers of the vessel were atheromatous. In the cavity of the left pleura were two pints of serum and some chronic bands of lymph. The left lung was universally condensed, and on section was seen to contain a large quantity of tubercle, generally in masses the size of a pea and larger. Some of these had softened, but there was no cavity. The intervening pulmonary tissue was condensed and hepatized. Right lung was voluminous, with a few miliary tubercles scattered through it. Abdomen.—Abdominal organs healthy. Commentary.—In this case during life it was carefully determined that the cardiac sounds were healthy, that the cardiac dulness was in- creased to twice its normal extent, and that there was unusual dulness above the Lft nipple in the sterno-clavicular region. These facts were subsequently explained by the demonstration, on dissection, of a healthy heart, of chronic pericarditis with effusion, and of a large aneurism springing from the transverse aortic arch, stretching towards the left side. Over the aneurism in this case no sounds were audible, a circum- stance probably attributable to the thick neck, by which it came off from the main vessel, as explained in the last commentary. The limb, which was the seat of the popliteal aneurism cured by compression, was subse- quently injected and dissected with care, and may be now seen forming a very fine preparation in the surgical collection of Mr. Spence of this city. The popliteal artery is completely occluded, the circulation having been maintained through the enlarged anastomosing vessels. Case CXXV.*—Aneurism of Lower Portion of the Thoracic Aorta, press- ing on the Thoracic Duct—Aneurism of Abdominal Aorta—Chronic Ulcer of Stomach—Chronic Tubercidar Abscesses of Liver and Right Kidney—Liver and Left Kidney Waxy—Leucocythemia. History.—Janet Young, aet, 50—admitted June 16th, 1854. States that her appetite has been impaired for the last three years, that she has been subject to chronic rheumatism, and last September had a severe bowel complaint, which lasted fourteen weeks. For the last ten years has suffered from vomiting, which has been more or less constant, and the matters ejected have occasionally been of a dark copper- color. Since the occurrence of the diarrhoea she has become very emaciated. Symptoms on Admission.—The whole body is extremely emaciated, and she is very weak. Tongue moist and clean. Appetite pretty good. No vomiting at present. Complains of pain and tenderness in the epigastrium, and on palpation a distinct tumor can be felt, with a strong impulse, a little to the right of the mesial line in the position of the pylorus. It is apparently solid, of uneven shape, about the size of a hen's egg; but its limits cannot be accurately determined. On auscultation over the tumor a loud blowing sound, synchronous with the aortic pulse, is audible. Bowels regular. Apex of heart beats between sixth and seventh ribs. Its size and sounds are normal. Pulse 88, of good strength. Urine pale, sp. gr. 1010, slightly * Reported by Mr. T. Walker, Clinical Clerk. ANEURISM. 619 coa^ulable on the addition of heat and nitric acid. Respiration and other symptoms normal. Habeat Syr. lodid. Ferri min. x ter indies. Progress of the Case.—On the 19th of June she commenced vomiting, a symp- tom which continued, with slight intermissions, during the rest of the month, generally coining on four hours after taking a meal. There was also considerable pain in the region of the tumor, which was relieved by the occasional application of two leeches, followed by warm fomentations. Various remedies were given with a view of checking the vomiting, of which small pieces of ice allowed to dissolve in the mouth appeared most effectual. Nourishment was frequently given in small quantities. During the months of August and September, the vomiting became far less frequent, although oc- casionally still distressing. All this time nutrients were constantly administered with wine, and although these were frequently retained, and even taken with appetite, the emaciation progressively increased. On examining the blood, it was found to possess an increased number of colorless corpuscles. A series of observations also was made to determine whether fat was passed in the faeces, but they were quite healthy, and the bowels on the whole were regular. She also slept well. During the months of Sep- tember, October, and November, she remained much in the same condition, occasionally complaining of a little more local pain in the epigastric tumor and abdomen, and latterly of cough and palpitation. For the next three months there was at times severe vomiting, but otherwise no marked change. The urine remained coagulable and of low specific gravity, occasionally presenting under the microscope a few waxy casts and pus corpuscles. During March the emaciation was apparently extreme, the pulse weak, and nutritive injections by the rectum were added to the nutrients and wine given by the mouth. The vomiting was greatly diminished, but for some days she suffered from conjunctivitis. There was also restlessness at night, which was relieved by morphia draughts. Her weakness very gradually increased, and without any other symptom she expired, April 16th, 1855. Seclio Cadaveris.—Forty hours'afier death. Thorax.—Both lungs had some puckerings near the apex, and contained some old tubercular matter. The heart was healthy. Near the lower part of the thoracic aorta was an aneurismal dilatation, about the size of a walnut, which projected to the left of the vertebral column, directly over the thoracic duct, which it appeared to compress. Abdomen.—Arising from the anterior part of the abdominal aorta, at the root of the coeliac axis and superior mesenteric artery, was an aneurism of a rounded form, about two inches in diameter, which projected forwards, and was nearly filled with firm layers of fibrin. Both the vessels named were thrust forward, separated to the extent of an inch, but were in themselves healthy. (University Museum, Prep. 2333, a.) The stomach was of natural size; on its lesser curvature, about half-way bet ween the cardiac and pyloric orifices, but rather nearer the latter, there was an ulcer of an oval form with depressed surface, callous margins and base, and about the size of a filbert. The edges were smooth, and dense as ligament, presenting on section a white glistening appearance, and in some places were a quarter of an inch thick. The liver weighed 2 lbs. On section it contained a number of masses of tubercular matter. Some of them had softened and given rise to abscesses. The hepatic tissue itself was waxy. The right kidney was very small, being 2+ inches long and 1J inch broad. On section there escaped a yellowish white fluid and some cheesy matter. The tissue of the kidney was quite gone, and its place supplied by the cavities, which presented the usual appearance of scrofulous abscesses. This kidney weighed one ounce. The left kidney was of large size and waxy. The spleen was natural. Commentary.—On the admission of this woman it became a question whether the tumor in the pyloric region was an aneurism or a can- cerous mass lying over the aorta. The symptoms were those of organic disease of the stomach. As the disease progressed and the emaciation became more urgent, the tumor could be more easily handled, and its rounded form and marked impulse favored the opinion of its being aneurismal. The frequent vomiting, however, still pointed to disease of the stomach, and served to explain much of the emaciation which existed, but not altogether, as it was observed that she Still retained a considerable amount of nourishment, especially at some lengthened 620 DISEASES OF THE CIRCULATORY SYSTEM. periods when the stomach was quiescent. The idea was then formed that there might be some disease at the head of the pancreas; but after careful examination, no unusual amount of fat could be detected in the stools. Latterly the vomiting was comparatively trifling, but still the emaciation was progressive, and became at length extreme. On dissec- tion after death, these facts were explained by the discovery of a small thoracic aneurism pressing upon the thoracic duct in addition to the abdominal one, which had become rounder and harder than when first observed. The lungs and liver exhibited well-marked examples of tuber- cular and scrofulous deposits which had been arrested in their progress. The diminution of the stomachic symptoms also was accounted for by the gradual healing and cicatrization of the gastric ulcer. It might have been supposed that the abdominal aneurism was progressing toward a spontaneous cure, as it was nearly filled with dense coagulated fibrin. The commencement of a thoracic aneurism above, however, sufficiently accounts for this, as will be explained more particularly in the commen- tary on the next case. Case CXXVL*—Aneurism of the Superior Mesenteric Artery and Aorta— Obscure Aneurism of Descending Thoracic Aorta—Treatment by the method of Valsalva—Pleuritis—Caries of the Vertebra, softening of Spinal Cord and Paraplegia—Sudden death by Poisoning with Tincture of Aconite. History.—Henry Smith, aet. 35, sailor—admitted December 19th, 1849. States that, about twelve months ago, while at sea, he received a severe blow on the back from the tiller of the vessel. He was knocked down and lay insensible for a short time. Since then he has experienced pain in the abdomen and back, and latterly pulsation in the abdomen, and a sensation of tingling and numbness in the thighs, legs, and feet, especially on the left side. States that about three weeks after the accident, he was admitted into the Liverpool Infirmary, where he remained for about eleven months. He was treated by opiates and other anodynes, and latterly also by leeching and cup- ping over the pained part of the abdomen. From this treatment he did not receive much benefit. Symptoms on Admission.—On admission, he is of a dark complexion; appearance strong and robust. A tumor is distinctly seen pulsating in the left hypochondriac region. It is of an oval form, and measures about three inches transversely; its long diameter cannot be ascertained, as its superior portion ascends below the ribs; but the inferior and lateral margins can be distinctly felt. He complains of great pain and tenderness in the region of the tumor, and of a beating which is increased on exertion, and also upon assuming the erect posture. He feels easiest when lying doubled up, resting on his elbows and knees, and in this position he is generally seen during the day. The pulsation of the tumor is forcible, synchronous with, or immediately suc- ceeding, the heart's impulse. On auscultation, a soft bellows murmur is distinctly heard over the tumor, and is loudest at the lower part. The apex of the heart beats about an inch below the nipple. Impulse tolerably strong. On percussion, the cardiac dulness extends transversely about two and a half inches. On auscultation, the sounds are normal in character; the first is heard loudest over the apex, just below the nip- ple ; and the second is most distinct at least three inches above and to the inside. He has no cough or expectoration. The right side of the chest is more resonant on per- cussion than the left, both in front and behind. On auscultation the respiratory mur- murs are normal. Appetite tolerably good. Bowels regular. Urine natural in quan- tity ; sp. gr. 1025, not coagulable ; presents a deposit of lithate of ammonia. Ordered a morphia draught at night. Progress of the Case.—December 23d.—Has never slept properly since his ad- mission. States that it requires a very large opiate to produce any effect upon him. Ordered to be bled to syncope, and his diet to be as follows: Breakfast, Bread, four * Reported by Messrs. H. M. Balfour, W. Clark, and A. Dewar, Clinical Clerks. ANEURISM. 621 ounces; milk, eight ounces. Dinner, Steak, two ounces; bread, two ounces. Supper, Bread, two ounces; tea, eight ounces. 24th.—He was bled to thirty ounces without syncope or nausea being induced. The blood drawn exhibits a distinct buffy coat. Pulse, 88, weak and soft. Pain easier, and sleeps better at night. 25th.—Dislikes beef for dinner, and would prefer a little rice pudding with the bread at dinner. To have one ounce of mutton and three ounces of rice pudding for dinner. Twelve leeches to be applied over the tumor. 26th.—Leeches bled freely, and he is now easier. Urine still presents a deposit of lithates. 30th.—Complains of constipation ; pain in abdo- men rather increased. To have Elect. Sennce 3 j daily. Ten leeches to be applied to the region of tlie tumor. 31st—Leeches did not bleed so well. Pain still severe. Applicct. Emplast. Cantharid. (3 x 3) parti dolenti. 1850, January 2d.—Blister gave some relief. Pulse stronger. Ordered to be bled to % xij. 3d.—The blood exhibited the buffy coat, but in a less marked degree than formerly. No faintness or nausea was induced. Two ounces of bread to be taken off his breakfast and half an ounce off his supper. To be allowed a bottle of lemonade daily, ith.—Sleeps very badly. R^ Sol. Mur. Morph. ; Tinct. Hyoscyam. aa 3 ss; Aquce 3 ss. M., to be taken every evening. 9th.—Sleeps rather better. Pain in tumor somewhat increased. Eight leeches to be applied. 10th.—Leeches gave relief. \3th.—Still complains of constipation. To have a colocynth and hyoscyamus pill daily. 16th.—States that for the last three or four days he has felt much stronger, and the pain and pulsation in the tumor have increased proportionally. Ten leeches to be applied. 11th.—Leeches gave relief, but still he does not sleep well. 21st.—Pulse tolerably strong. Ordered to be bled to syncope. 22d.—He was bled yesterday to twenty-six ounces, without inducing faintness or nausea. To-day his pulse is weak and soft, and he expresses himself much easier. The blood exhibited a distinct buffy coat. Urine loaded with lithates. 25^.—Yesterday he was ordered to be bled until some faintness was induced, and 28 oz. were abstracted before that effect was occasioned. To-day the blood is cupped, the pulse weak, and the urine loaded with lithates. A chloroform draught at night. 29th.—Again bled to 10 oz. Feb. 8th.—Great pain in the tumor at night, preventing sleep, for which sedative draughts and enemas afford little relief. 20 oz. of blood were in consequence taken from the arm to-day, which pro- duced faintness, and at once removed the pain. 19th.—Size and impulse of tumor evidently diminished. Does not think he is much weaker since admission, but is un- able to sit up so long. Pulse small. To-day pain returned in tumor. 12 leeches to bs applied. March 2d.—Bl& yesterday to 14 oz., without inducing syncope. Blood not buffed. 10^A.—Pain returned with violence. Again bled to 23 oz. 19th.—Again bled to 8 oz. He has continued on the low diet, which was altered to-day as follows:— Breakfast, 1 biscuit (IJ oz.); tea, half a pint. Dinner, 2 biscuits (2^- oz.); eggs, 2. Supper, 1 biscuit (l£ oz.); tea, half a pint. The analysis of the blood drawn on the 19 th h as folioW3:— Specific gravity of serum.....1028 Solids in 1000 pcirt3:— Fibrin......... 4-6 Globulc3........42-7 Serous solid:;.......88-2 Water .......... C64'o Total 1000 April 6th.—Bled again to 13 oz. 15ft—Was strong enough to walk in the back- green, but felt exhausted after it. 21st.—Bled yesterday to 34 oz., at his urgent re- quest, insisting that he felt nothing, until he fell back in a state of syncope, from which he slowly recovered. To-day appearance anemic, pulse feeble, feels weak. May 5th.—Has been suffering from constipation, which has been relieved by colocynth and henbane pills. Pulsation in the tumor evidently diminishing. To-day, com- plains of shooting pains in the back, between the shoulders, and down the arms. As he dislikes the eggs, 4 oz. of calves'-foot jelly were ordered instead, the other articles of diet remaining the same. June 1st.—Considerable pain, and no sleep for three days. 8 leeches to be applied. 11th.—2 oz. of meat instead of the calves'-foot jelly. July 11th.—Has occasionally been walking a little in the open air, which, however, causes some pain. Apply 12 leeches. Aug. 9th.—Pain on walking, caused by hemorrhoids, for which injections of cold water have been ordered with benefit. 16th.—Pain in tumor returned. Apply 12 leeches, which caused faintness, for which § ij of wine 622 DISEASES OF THE CIRCULATORY SYSTEM. were given. 30th.—Went out of the house yesterday by permission. Oct. 20th.__ Has been allowed to go out of the house once a week for exercise. To-day pain in tumor severe. Apply 8 leeches. 25th.—The tumor was observed to be movable to- day. When he lies on his left side, the prominence is concealed below the cartilages of the ribs, but when he turns on his back, it moves three or four inches towards the right side. He says he has only noticed this mobility during the last week. Nov. 20th.—Complains of a sharp pain under the left clavicle, and six leeches were applied there in consequence. 26ih.—Pain under clavicle continues, but was removed by cupping on the 22d and to-day. Dec. 21th.—Bled to 3 viij, to remove pain in tumor. 1851, February 11th.—Since last report, has continued to feel pain in the tumor. Again bled to § viij. 20lh.—Present diet: Breakfast, one roll and tea; Dinner, part of a fowl and two potatoes; Supper, one roll and tea, wine § iv. The tumor now feels hard and solid, is the size of a pigeon's egg. March 30th.—Bled to % vj. April 2d.—Bled to 3 xij. The bleeding generally relieved the severity of the pain, but on this occasion failed to do so, and a blister was applied. May 2d.—Bled to 3 x, with relief. 30th.—11 leeches were applied. June 1st.—No relief followed the application of leeches. To be cupped on the back to § vj. June 8th.—Pain not diminished, and he was bled to § xij, which caused great relief. 24th.—Cupped to § viij. 26$.— Bled to § xij. Oct. 29lh.—Bleeding has been occasionally resorted to, to relieve pain; otherwise he has remained the same. Diet at present is: Breakfast, one roll and a pint of tea ; Dinner, one flounder and two potatoes; Supper, one roll and pint of tea, brandy, § iij. Dec. 12th.—Since last report has been comparatively easy, getting up daily, and feeling pain only for about two hours after rising in the morning. To-day, the pain having increased, 12 leeches were applied. 1852, January 10th.—Complains of weakness, so that he is obliged to use a stick in walking. 15th.—Tumor fully the size of a walnut. Aneurismal murmur greatly diminished. Complains of numbness in left side, and pain in right leg. Walking is more difficult. Bled to § viij. 23d—Weakness in lower extremities during walking increased. On the 29th, was seized with general coldness, without distinct rigor. He had also severe pain in the left side of the chest, increased on inspiration. 30th.— There is frequent cough, and copious expectoration not tinged with blood. The left shoulder is also very painful. Skin hot, total loss of appetite, great thirst, pulse feeble, great prostration. On percussion, the whole of the left side of the chest is dull through- out. On auscultation, the respiration is feeble superiorly, and inaudible inferiorly. A friction noise is heard external to the nipple. No crepitation can be discovered ante- riorly or posteriorly. Mixture of ipecacuanha and morphia ordered. 31st.—Cough and pain diminished. Feb. 2d.—Sputum slightly tinged with blood. 4th.—Cough and expectoration diminished. Sputum consistent, free from blood. Friction still present anteriorly, aegophony posteriorly. 8th.—Return of pain in chest and shoulder. Phy- sical signs the same. Blister to left side. 16th.—Dulness less below left clavicle, and slight motion of ribs observed there during respiration. March 1st.—Friction now audible over the whole of left side of chest posteriorly, and over apex of lung anteri- orly. Percussion clear over upper third of lung, but still completely dull inferiorly. Pain, cough, and febrile symptoms have now disappeared. A bedsore has formed in the sacral region, which has been poulticed, and now exhibits a disposition to slough. The abdominal aneurism has undergone no change. Decided paralysis of motion in the inferior extremities, but their sensibility is unaffected. March 8th.—Slough has separated from sacrum. April 8th.—Since last report, paralysis in inferior extremi- ties has become complete. He has lost all voluntary power over them, and when they are pinched or pricked, no sensation is produced. He experienced, however, twitch- ings and startings in the paralysed limbs, but no pain. His evacuations are passed in bed, and the sore on the sacrum continues to discharge. In this state he continued until May 31st,—the lower limbs paralysed, but, with the exception cf increasing weakness, much the same as at last report. To-day he swallowed a considerable por- tion of a iiniment, containing one-fourth its volume of tincture of aconite. He rapidly became pulseless. The intelligence, for three or four minutes, was unaffected. The respiration was embarrassed, and he was dead in a period variously estimated at from five to seven minutes. Sectio Cadaveris.—Twenty-five hours after death. Thorax.—General firm adhesions between pleuras on the left side ; on the right side, slight adhesions between pleurae at the apex. The pericardium contained three and a half ounces of straw-colored serum ; the blood everywhere fluid; heart ANEURISM. 623 healthy; right lung mostly crepitant, with considerable induration and puckering at the apex. On section, several cretaceous encysted concretions existed in the pul- monary tissue at the apex, surrounded by considerable carbonaceous deposit. Here and there also small portions of the lungs were collapsed. The left lung somewhat compressed posteriorly, but otherwise crepitant, and apparently normal. It is at- tached at the posterior part of lower lobe to a sacculated tumor, the size of a foetal head, in front of the dorsal vertebrae, evidently arising from the descending aorta. The tumor is situated more to the left than to the right side, and, on being cut into, is found to be only partially filled with recently coagulated blood. At that part of the sac which is adherent to the lungs, its wall is strengthened by the depo- sition of fibrin in laminae, the whole at its thickest part being an inch thick. The bodies of the 5th, 6th, 7th, and 8th dorsal vertebras were to a great extent absorbed, being apparently scooped out, leaving the intervertebral cartilages prominent between them. The caries had also affected the heads of the corresponding ribs on the left side. Posteriorly the tumor had projected about an inch, presenting an oval, rounded surface, which had compressed the spinal cord for about an inch and a half of its length opposite the 8th and 9th dorsal vertebrae. On removing and bisecting the cord, its medullary substance at the compressed portion was somewhat softened, an alteration much more marked for two inches both above and below where it was pultaceous, gradually passing into the spinal medullary matter of normal con- sistence. The softening was white throughout, with no red' spots. Abdomen.—The pancreas is stretched over an abdominal tumor, the size of a small cocoa-nut, in front of the aorta, which is movable, and tolerably resistent and firm. The stomach was healthy, and about a third full of pultaceous lumpy matter, smelling strongly of linimentum saponis. The other abdominal organs were healthy. On dissecting the tumor, it was ascertained to be an aneu- rism formed at the root of the superior mesen- teric artery, and partly involving the anterior wall of the descending aorta. It was of an oval shape, with one extremity resting on the vertebrae, the other lying immediately below the integuments. Its long diameter measured four, and its transverse three inches. On taking off a thin slice on the left of the tumor, so as not to interfere with the exit of the mesenteric artery, it was seen to be almost wholly occupied by concentric layers of fibrin, except where a channel, larger near the aorta, but becoming smaller at its distal extremity, allowed a free communication of blood with the efferent vessel, Fig. 441. (Uni- versity Museum, Prep. 2229). Microscopic Examination. — Portions of the spinal cord when examined under the mi- croscope, with a power of 250 diameters linear, were everywhere ascertained to consist of broken up medullary tubes. Many of the varicosities j-ig_ 447 had enlarged and separated, forming round, oval, and variously-shaped transparent corpuscles, with double lines, mixed with fragments of the tubes, and numerous molecules, granules, oil globules, and broken- down ganglionic cells. No granular corpuscles were anywhere visible. Commentary.—This case was in the Infirmary two years and a half, and during the whole of that time its progress excited unusual interest. We had to do with,—1st, A thoracic aneurism ; 2d, An aneurism of the Fig. 441. View of the thoracic and abdominal aneurisms, the carious vertebra:, etc. 624 DISEASES OF THE CIRCULATORY SYSTEM superior mesenteric artery;* 3d, The treatment of aneurism by Valsalva's method; 4th, Acute passing into chronic pleurisy; 5th, Gradually in- creasing, and at length complete paraplegia; and 6th, Poisoning by aconite, and the most rapid death by that drug on record. [ shall notice the principal facts of his case in succession, point out the difficulties of the diagnosis, the effects of the treatment employed, and state what oc- curs to me with regard to the mode of his death. The Thoracic Aneurism.—The thoracic aneurism in Smith's case was not suspected during life. On looking back upon the facts observed when he was admitted I find that, after receiving the injury which pro- duced the disease, he complained of pain in the back, as well as the abdomen. It is also stated that, when admitted into the Infirmary, " the right side of the chest is more resonant on percussion than the left, both in front and behind." These facts were too vague at the time to enable me to distinguish a thoracic aneurism in addition to the abdomi- nal one, more especially as the respiratory murmurs were normal; there was no cough, expectoration, or other pulmonary lesion. The idea, therefore, of a thoracic aneurism never occurred to me, nor, if it had, is it likely that it would have been confirmed, although now, on looking back, the importance of the facts above stated are apparent, and prove that such aneurism really existed when he first came into the house. On going over the reports which were kept of his progress during the two years and a half he was in the Infirmary, I find it stated that, on the 6th of April, when under the care of Dr. Christison, he " com- plained of shooting pains in the back, between the shoulders, and down the arms." On the 20th of November, in the same year, when under Dr. Alison's care, he " complained of a sharp pain under the left clavicle." On both occasions the pain was of short duration. I can find no other symptoms which could be attributed to the thoracic aneurism until the 29th of January 1852, when he was seized with all the symptoms of acute pleurisy. For a long time previously his chest had not been examined, but when, on this occasion, it was percussed, the whole of the left side was found to be dull, both anteriorly and posteriorly. This, as well as all the other symptoms -noticed at that time, were ascribed to pleurisy with a large amount of exudation, and on carefully weighing these symptoms and physical signs, I do not see how we could have arrived at any other conclusion; for a pleurisy did certainly exist, as proved by the friction during life, and by the dense chronic adhesions found after death, although now we can have little doubt that the dul- ness, increased vocal resonance, and other signs, were for the most part dependent on the aneurismal tumor. Another symptom usually pre- sent in thoracic aneurism was absent, viz., haemoptysis, or bloody sputum. On one occasion only was this observed, viz., on February 2d, four days after the pleurisy was established. I remember that it induced me to examine his chest with the utmost care, with a view of discovering if pneumonia also existed ; but as stated in the report, no crepitation could * For other cases of aneurism of the superior mesenteric artery, see case by Dr. Donald Monro, in " Observations on Aneurism," by the Sydenham Society, p. 130; bv Dr. Klliotson, in Lancet, August 29, 1835; by Dr. Arthur Wilson, Medico-Chir. Transactions, vol. xxiv.; by Mr. James Douglas, in Medical Gazette, February 25, 1842; by Dr. W. Gairdner, in Monthly Journal of Med. Science, January 1850; by Dr. John Ogle, in Trans, of Patholog. Soc, vol. viii.; and by Dr. Haldane, in Edinb. Med. Journal, October 1858. ANEURISM. 625 anywhere be discovered. I am satisfied, from the careful examination at that time, as well as when he first came into the house, that there was no blowing or other abnormal sound in the chest caused by the aneurism. It is not to be wondered at, therefore, that from this period the dulness on the left side of the thorax, unaccompanied with other symptoms, should be referred to chronic pleurisy, rather than to a thoracic aneurism. It so happened, also, that there was a man in the ward laboring under chronic pleurisy on one side, who presented all the thoracic symptoms and signs which existed in Smith. It appears, there- fore, that the detection of the aneurism was almost impossible; for, supposing even that it had been suspected, and that attention had been directed to confirm such a theory, I am not aware of any arguments by which it could be supported. An idea, however, that it would be im- possible at any time to discover such an aneurism, would be erroneous, and would do discredit to physical diagnosis; for there can be little doubt that had the chest been carefully re-examined—say a short period before the attack of pleurisy—I think it would then have been apparent that a tumor existed in the chest, and if so, that tumor, from its seat and concomitant circumstances, would have been declared to be aneurism low down in the thorax. It was simply because no suspicion of its existence occurred to us, and because no physical examination of the chest was made at that time, that the tumor was not detected during life. 8 The Abdominal Aneurism.—When Smith entered the house the abdominal aneurism was of considerable size. It measured three inches across. Its inferior and lateral margins only could be felt, the superior portions being covered by the ribs. The impression conveyed to me by examining the tumor, however, was that it was about the size of a cocoa-nut. It was prominent, especially when he stood up, and pulsated strongly. There can be no doubt that its volume must have undergone considerable diminution; for, previous to his death, it felt through the integuments about the size of a small hen's egg;—in some of the re- ports, it is said of a pigeon's egg, and of a walnuti. Yet, as you see, it is the size of a large orange, elongated. Its form is a long oval, one extremity of its long axis resting deep upon the vertebrae', the other directed toward the skin. Hence, during life, we could only feel one of its rounded ends. You observe, however, that the whole tumor is dense and resistent,—and on section it presents numerous concentric laminae of coagulated fibrin, with a small canal running through the centre keeping up the communication between the aorta and the superior mesenteric artery. The man presented habitually a jaundiced skin, which was doubtless owing to the pressure of the tumor on the duo- denum and biliary ducts. The Paraplegia and Spinal Softening.—He first complained of weakness in the lower extremities early in January 1852; at the end of that month my period of attendance on the wards ceased. In the icport of March 1st, I find it stated that there was decided paralysis of motion in the inferior extremities, while sensation still resulted when they were touched. On April 8th, the paralysis was complete—that is, volition failed to cause movement in the lower extremities, and sti- 40 626 DISEASES OF THE CIRCULATORY SYSTEM. muli applied to them failed to induce sensation. Involuntary move- ments, however, occurred, consisting of twitchings and startings, but he never had pain in the limbs. In cases of myelitis the usual symptoms are, pricking and tingling in the soles of the feet. These symptoms were absent, and the reason of this may, I think, be found in the nature of the softening in the spinal cord. It contained no granular cells, the result of exudation, and its transformation into fatty granules; but the tubular substance of the cord was broken down, forming round and oval fragments of the tubes. Hence it was a mechanical softening, the result of gradual pressure merely. These distinctions have not been hitherto sufficiently attended to in pathology. (See p. 358.) You will observe that the aneurismal tumor commenced pressing on the left side, and from before backwards, and the symptoms indicate that weakness was felt in the left inferior extremity before the right one was affected,—and that motion was paralysed first, sensation last. Treatment by Valsalva's Method.—A short time previous to the admission of Smith, I treated another case of abdominal aneurism by the method of Valsalva, for a period of forty days,—at the expiration of which time, he walked out of the house, with little assistance, to the nearest cab-stand, a distance of nearly 250 yards, and left the city.* In the case of Smith, therefore, the bleedings were more frequently repeated, and greater in amount, while the diet was even more diminished; and yet, after nearly a month's treatment, the pulse was of such good strength, that I ordered venesection to syncope—an effect that was not produced after the loss of twenty-six ounces of blood—so that the clerk, afraid to proceed further, bound up the arm. Three days afterwards, twenty- eight ounces of blood were removed, with the effect of only producing a feeling of faintness. Similar bleedings were practised at no distant inter- vals, besides numerous applications of leeches, and the restricted diet; and yet the report of 21st April 1850 is, that " he was bled to thirty- four ounces, at his urgent request, insisting that he felt nothing, until he fell back in a state of syncope." I am induced to suppose, therefore, that in this case, as in the preceding one, the treatment had not been carried out to its full extent. The nurse, indeed, now informs me, that perhaps during the first two months his diet was really limited; but she thinks so, simply because at that period he suffered great pain, and seemed very anxious to follow the advice given to him. Subsequently, there is every reason to suppose that he obtained food from his companions, or from some other source. I find from the reports, indeed, that whilst his diet was still nominally at a very reduced amount up to July, he was at the same time walking about with considerable vigor. From my attempts at carrying out Valsalva's treatment in these two cases, I con- clude that it is impossible to practise it on patients in an open ward, or indeed under any circumstances, without a degree of surveillance that it would be very difficult to obtain. The good effects of the treatment, notwithstanding its imperfect nature, were so evident as to strike all who witnessed it, and to cause the patient continually to request that he might be bled. In fact, after every general bleeding, the dragging pains, and other uneasy sensations * See Monthly Journal, February 1850, p. 169. ANEURISM. 627 he experienced in the abdomen, invariably left him, and he enjoyed longer or shorter periods of perfect ease; then, as the pain gradually returned, and it became unbearable, he was agaiu relieved by bleeding ; and so on. During the progress of his case, also, it was observed that the abdominal tumor gradually diminished in size, and became harder. In October, the tumor was ascertained by Dr. Christison to be some- what movable; but in the following December, when I examined it, it was again stationary. During the whole of 1851 he enjoyed compara- tive comfort,—occasionally, however, feeling abdominal pain, which was relieved by leeches or bleeding. At the beginning of 1852, the general opinion of all who examined him was, that, on the whole, this case was a remarkable example of the good effects of Valsalva's treatment. Then, however, the paraplegia came on, indicating that the disease was really not conquered, but, by its pressure backwards, was affecting the spinal cord. Then came the attack of pleurisy and the paraplegia; and from this period it was evident the disease would, terminate fatally. The examination of the body after death was, in this case, not only important, as determining the nature of the aneurism, and in a diagnostic point of view; but it served, in my opinion, to point out what value ought to be attributed to Valsalva's treatment. It affords an example of a wide generalisation to which the cultivators of rational medicine have been gradually tending,—viz., that not only is the examination of the body after death necessary for diagnosis and pathology, but that it is essential, in order that we may properly appreciate therapeutics, and the utility of different plans of treatment. Let us suppose, for instance, that this man had died at the commencement of 1852 from the attack of pleurisy, and that, as so often happens, we had been refused permission to open the body, my conviction i3, that under such circumstances this case would have been recorded in the annals of medicine as a successful instance of cure by the method of Valsalva. But now, when all the facts are before us, it is evident that the diminution of the abdominal swelling was owing to the increase of the thoracic one; and that, as the force of the current of blood became lessened by the enlargement of the aneurismal dilatation above, so the flow of blood was retarded in the tumor below. In consequence, the concentric depositions of fibrin, the lessened size of the abdominal swelling, and the more permanent relief of pain, instead of being attributable to the treatment, as we had supposed, must now be more rationally ascribed to the increase of a thoracic aneurism, not detected during life, which had produced these results mechanically, and altogether independently of art. The treatment of internal aneurisms by the method of Valsalva, has for some time been discouraged in this country, on the ground that it gives rise to a general irritability, and to symptoms of a distressing nature, which are often intolerable; whilst, on the other hand, it is seldom attended by a permanently good effect. In the case before us, as well as in that I formerly treated, no unpleasant symptoms could fairly be ascribed to the practice; but, on the contrary, it produced (especially the bleedings) well-marked relief. The question of the permanency of these good effects is, I admit, in no way supported by my experience. But another important practical point, namely, the temporary relief 628 DISEASES OF THE CIRCULATORY SYSTEM. which bleeding causes, without arresting the progress of organic mala dies, here meets with an excellent illustration. Poisoning by Aconite.—The facts which I have been able to make out regarding the poisoning of this man are as follows :—On Monday, May 31st, about 11 o'clock in the morning, the attention of Mr. Broad- bent (non-resident clerk) and of Dr. Murchison (resident clerk), both of whom were at the time in the ward, was directed to Smith, by a groan or cry. He was then observed to be sitting up in bed, leaning forward, and groaning like a man laboring under colic pains. Mr. Broadbent, who was nearest at the time, went to his bedside, and asked, " What is the matter ? " Smith made no immediate reply, but continued to groan, and moved his arms in a feeble manner, and it was noticed by Mr. B. that his hands dropped considerably when the arms were raised. He then tried to reach the spit-box, but not being able to do so, it was given to him, and he seized it, raised it to his mouth, and spat into it. He then said, with short pauses between his words, " Is there anything wrong with my face ?—it is very painful; what medicine have I been taking?" On being asked to point out the bottle on the shelf, he did so, saying, " That little bottle there." On looking at it, Mr. Broadbent saw by the label that it was a liniment, composed "of Tr. Aconiti § ss; Lin. Saponis c. Opio gjss. Dr. Murchison, on being informed what had happened, also went to Smith, found him pulseless, and on letting go his arm observed that it fell down powerless at his side. Smith then repeated more than once, " Can nothing be done for me ?—What can you do for me ?—Can you get me a vomit ? " etc. An emetic of sulphate of zinc was immediately sent for, and it was further observed that the pupils had undergone no marked change, that there was no lividity of the lips or other part of the countenance, that no impulse could be felt in the cardiac region, and that the respiration was more slow and labo- rious than usual. Dr. Murchison now left the patient to get a stomach- pump, and Mr. Broadbent saw Smith retch twice, as if endeavoring voluntarily to vomit. He therefore went into the side-room to get a feather, or some object to tickle his fauces with, but was immediately summoned back by the intelligence that Smith was wors^e. On returning to the bedside he found that the patient had fallen on his bed, the head thrown back, face and lips remarkably pale, a little saliva running from the corner of the mouth, the respirations occurring at long intervals with gasping, the pupils neither dilated nor contracted, and the eyelids paralysed, when opened remaining fixed, and not contracting on blowing into the eye. He was now insensible, and consequently the emetic, which at this time arrived, could not be given. About a minute after, Dr. Murchison, on hurrying back with the stomach-pump, found him dead. Notwithstanding, more than a pint of semi-pultaceous matter was immediately drawn off from the stomach, smelling strongly of the lini- ment, and artificial respiration was kept up in vain for five minutes. The period that elapsed from first noticing Smith's cry or groan until Dr. Murchison's return, when he was dead, is differently estimated by the gentlemen concerned at five and seven minutes. The liniment con- sisted originally of Liniment. Sapon. C. Opio f jss; Tr. Aconiti § ss, and it is believed that the whole of this quantity (viz. two fluid ounces), was ANEURISM. 629 in the bottle when Smith began to drink it. There were found in the bottle afterwards five drachms remaining, so that the presumption is, that he swallowed three drachms of laudanum, and upwards of two drachms of tincture of aconite. Whether Smith's death arose from accident, or whether he com- mitted suicide, is not likely ever to be known. Those who knew him best in the ward, as well as the nurse, are of the latter opinion, based principally on the character of the man, which was such as to prevent his mistaking a liniment for a draught. It seems also, that no one was more habitually careful as to the medicines he took,—that the liniment was not ordered for him ; that he took it from a patient in a neighbor- ing ward, and kept it on his shelf for some days; and lastly, that since the paraplegia had become complete, he had been unusually despondent and morose. With regard to the phenomena produced, it is most likely that, immediately after swallowing the poison, he experienced those violent tingling and stinging sensations in the mouth and fauces which aconite produces, and hence the pain complained of in his face. Being already paraplegic, nothing is known as to how far the poison affected the muscles of the lower extremities; but it is evident that, whilst the intelligence remained perfect, the arms became weak, then powerless. Subsequently, he could not support himself in the sitting posture; and, on his falling back, the muscles of the face and of respiration were paralysed, and he died asphyxiated. Previous to this, however, a powerful sedative effect had been produced on the heart, for when first noticed he was pulseless, and shortly after, no impulse could be felt in the cardiac region. According to Dr. Christison, the least variable symptoms of poison- ing by aconite in the human subject are, " first, numbness, prickling, and impaired sensibility of the skin, impaired or annihilated vision, deafness, and vertigo—also, frothing of the mouth, constriction at the throat, false sensations of weight or enlargement in various parts of the body,—great muscular feebleness and tremor, loss of voice, and labori- ous breathing,—distressing sense of sinking, and impending death,—a small, feeble, irregular, and gradually-vanishing pulse,—cold clammy sweat, and pale bloodless features, together with perfect possession of the mental faculties, and no tendency to stupor or drowsiness; finally, sudden death at last, as from hemorrhage, and generally in a period varying from an hour and a half to eight hours."* Although in this case many of the symptoms just mentioned were not noticed, it must be evident that the leading ones, indicative of the physiological action of the drug, were observed. When the large dose of the poison is con- sidered, and the great rapidity of its effects, it may be easily under- stood how the minor symptoms, and especially those having reference to the sensations of the patient, were not ascertained, if indeed they really existed. Dr. Fleming considers that aconite may cause death, " first, by pro- ducing a powerful sedative impression on the nervous system; second, by paralysing the muscles of respiration; and third, by producing syncope." He observes, " that the second mode of death has never been * On Poisons, fourth edition, page 871. 630 DISEASES OF THE CIRCULATORY SYSTEM. recognised in man; the quantity of the poison taken in no case having been sufficient to exert such an effect on the nervous and muscular systems as is necessary to induce it."* The case of Smith, indeed, is the only one of this description, so far as I am aware, that has ever occurred in which the dose of poison was so large, and the death so rapid. It is difficult to separate the effects of syncope from those of asphyxia in such a case, as the first condition must induce the other. Both were apparently combined. It is also difficult to determine how far the effects on respiration were occasioned by paralysis, creeping from below upwards, as in the case of Gow, formerly given (Case XL VIII., p. 459). There are some facts, however, noticed by Dr. Christison, which lend support to such a doctrine; and it will be observed that paralysis of the hands and arms preceded that of the muscles of the back and face in the case of Smith. The general diagnosis of thoracic aneurisms has always been con- sidered a matter of great difficulty. When, indeed, a tumor with a distinct impulse is perceptible, we, in the majority of cases, know with what disease we have to do. But even here occasional errors by men of the greatest experience have sufficiently proved that the art of detect- ting these tumors with exactitude is imperfect. Again, when aneuris- mal tumors are seated at the upper part of thorax, it is important to determine whether they arise from the aorta, or from the large vessels coming from it, and if the latter, which vessel is affected. Then aneurisms originating from the upper part of the descending aorta press upon neighboring nerves, as the superior and inferior laryngeal and pharyngeal branches of the pneumo-gastric, giving rise to various symp- toms ; or they compress the larynx, trachea, bronchus, oesophagus, or the lung itself, and so occasion laryngeal, oesophageal, or pulmonary symp- toms. Lastly, when deep in the thorax, their progress is often latent. Hence the signs and symptoms of thoracic aneurisms vary—1st, Ac- cording to their scat; 2dly, According to the size of the tumor and its pressure upon neighboring parts; 3dly, On the character of the aneurism, its formation, and state of the vessel. The means at our disposal for detecting these aneurisms are,—1st, Percussion ; 2d, Auscultation ; 3d, Palpation ; 4th, Symptoms. 1. Percussion.—That the situation and size of the aorta can be accurately determined by percussion, was first proved by Piorry.f I have frequently succeeded, in favorable cases, in marking out on the chest the size of this vessel. To do so with accuracy, it is first necessary to limit the margins of the heart in the manner previously explained (see p. 56), and then carrying the pleximeter upwards in the course of the aorta, and over the sternum, the dulness of the vessel when com- pared with the resonance of the lung on both sides, may be made very apparent. In the same manner, the extent of saccular, or simple aneu- risms by dilatation, may frequently be determined with accuracy when seated in the ascending or transverse arch. In such cases, however, the existence of pain often renders percussion impossible, and at all times * An Inquiry into the Physiological and Medicinal Properties of the Aconitum Napellus. Edinburgh, 1845. P. 42. De l'Examen Plessimetrique de 1'Aorta, etc. 1840. ANEURISM. 631 it should be conducted with great gentleness. When an aneurism ia seated in the descending thoracic aorta, its limitation is more difficult, as we have then to percuss through the lung anteriorly. But careful manipulation, and varying the force of the blow, together with percus- sion posteriorly, will frequently enable us to determine the position and size of the swelling. If, on the other hand, the aneurism be small and deep-seated, while the lungs are healthy, and if, at the same time, no suspicion of the disease be entertained by the practitioner, he is very likely to overlook the importance of slight dulness on one side of the chest. 2. Auscidtation.—There may be no sounds heard over an aneurism, and when present they may be either single or double. Considerable discussion has taken place whether, in the latter case, the second sound originates in the tumor, or is propagated along the vessel from the heart. This is a theoretical point which is not yet decided. Whether single or double, they must be judged of according to their character and seat. With regard to their character, they may be,—1st, Soft and blowing; 2d, Harsh and rough (in the latter case, the vessel is generally diseased, and its lining membrane more or less atheromatous or calcareous); 3d, There may be a peculiar clink, or abrupt harsh resonance, approaching towards, but never reaching, a metallic sound. It is generally heard when a saccular aneurism, free from coagula, is present, with a small opening, having thin and elastic margins. With respect to the seat of these sounds, when near the heart, they are generally synchronous with those of that organ, and their discrimination is very difficult. When situated in the arch of the aorta, there is a distinct separate source of sound. This latter can only be successfully studied by carefully com- paring the moment of impulse of the heart with that of the tumor, as well as the character and intensity of the cardiac and aneurismal sounds. You should carry the stethoscope carefully from one to the other, and observe the diminution and increase of the murmurs, as you lengthen or shorten the distance from the origin of the sounds. It is necessary also to study the direction in which the sounds are propagated—those of a blowing or rasping character having a tendency to pass in the direction of the current of blood. Hence in aneurisms of the innominata, the murmur is prolonged in the course of the right carotid and axillary arteries, while those of the aortic arch, and especially its descending portion, may be heard in the aorta, on applying the ear to the back. In this manner careful and repeated auscultation, conjoined with percussion, will enable you, in the majority of cases, to determine exactly, not only the existence and seat of the aneurism, but in many cases its form and structure. 3. Palpation.—When an aneurism points externally, at umor and an expansive impulse can be felt by the hand. The position of the tumor varies according to the part of the aorta, or the large vessels from which it originates. Thus, saccular aneurisms immediately above the aortic valves pass downwards. When situated in the innominata, they manifest themselves above the clavicle on the right side. If originating in the transverse portion of the arch, there is often no external tumor; and when it does occur, it generally 632 DISEASES OF THE CIRCULATORY SYSTEM. appears on the left side of the sternum, above or below the sternoclavi- cular articulation. Aneurisms lower down in the arch are most com- mon in the left thoracic cavity. These rules are by no means absolute; for, although an aneurismal tumor for the most part tends to enlarge in the direction in which the impulse, from the course of blood, is applied—this, in several cases, cannot be determined in the living body. The impulse of the tumor is synchronous with, or follows the systole of the heart. Occasionally there is no impulse, a circumstance most frequently observed when the tumor does not present externally, and is only determined by percussion. The pulse of arteries connected with the aneurism may be weakened or retarded. The pulse at both wrists should be always carefully studied; for if one be weaker than the other, it is clear that an interruption exists in the current of the blood in the axillary artery. This may arise from two causes—1st, From the vessel being involved in the tumor; 2d, From its being compressed by it externally. The former condition exists most commonly when there is aneurism of the innominata, when the weaker pulse will be on the right side. In aneurisms of the arch, on the other hand, the feebler pulse is usually on the left side. The retardation of the pulse, when it occurs, is owing to causes very similar to those which affect its strength. 4. The symptoms which are present in cases of thoracic aneurism vary according to the size of the tumor, and the parts on which it presses. When seated at the upper part of the chest, it may, by pressure on the larynx, produce alteration of the voice, more or less harsh cough, and stridulous respiration; by affecting the branches of the eighth pair, occasion increase or diminution of their special functions; impede deglutition by constricting the oesophagus; or modify the respiratory murmur by pressing on the trachea or larger bronchi. Occasionally there is a crepitating murmur in the lung, with many of the signs and symptoms of pneumonia, for whieh it has often been mistaken, including rusty sputum, dulness, and increased vocal resonance. Pressure of the tumor on the axillary vessels and nerves may induce more or less oedema of the extremities, and paralysis more or less complete. Some- times there are dull, gnawing, or lanoinating pains in various parts of the ehest; but nothing is more remarkable than the size and formidable nature of some aneurisms which have caused little ^ain. Occasionally there is a feeling of oppression and constriction—dyspncea with or with- out exertion, and haemoptysis to a greater or less extent. The combination of the results obtained by percussion, auscultation, palpation, and vascular impulse, and the functional symptoms, vary in- finitely in different cases, and their careful detection, combined with a knowledge of physiology, will in the majority of cases enable us to form a correct opinion as to the nature of the disease. It must not be for- gotten, however, that there are some cases which have been so obscure as to baffle the efforts of the most able physicians; and that, generally speaking, the deeper the aneurism the greater the difficulty of detecting its exact nature, and the complications connected with it. It is also well ascer- tained that the symptoms may be simulated by a tumor situated out- ANEURISM. 633 side and upon the vessel; and occasional mistakes, made by the most experienced surgeons—men, who, during their professional lives, have carefully examined a large number of these tumors—prove the excessive difficulty of detecting aneurisms, even when situated in the limbs or in the neck. How much more difficult must be the appreciation of these symptoms, when the aneurisms are below the sternum or clavicles, not to speak of their occurrence deep in the thorax. Yet these very symptoms, together with the results obtained by percussion and ausculta- tion, enable the physician frequently to overcome the greatest difficulties, and to demonstrate what may properly be called the greatest triumph of his art. The physical phenomena most distinctive of abdominal aneurism are a swelling more or less defined, an expansive impulse on applying the hand, and a bellows murmur synchronous with, or immediately following, the heart's systole on applying the stethoscope. This bellows murmur is generally loudest over the tumor, and is propagated down the aorta— although, when immediately below the diaphragm, it may be confounded with the first sound of the heart. The symptoms are very various, con- sisting of dragging, or other pain, more or less acute and prolonged, owing to pressure and stretching of the neighboring nerves, together with functional disturbance of one or more of the abdominal viscera. Various cases on record, therefore, have presented a train of very anomalous symptoms, and at various times been considered as different diseases by medical practitioners. A complete re-investigation of the symptoms and signs of abdominal aneurisms is much required. This is a task, how- ever, which will require a thorough knowledge of all that is now known of physical diagnosis and morbid anatomy, combined with great powers of observation, and such opportunities as fall to the lot of few individual members of the profession. The pathology of aneurism is sufficiently treated of under the heads of " Vascular Growths," p. 216, and of " Fatty Degeneration of Blood- vessels," p. 256. The latter, by inducing weakness or want of elasticity in the vascular wall, permits of its dilatation by the successive impulses of the blood on the enfeebled tissue. Occasionally the inner coat of the vessel is lacerated by external violence, or by sudden exertions, when a similar morbid condition gives rise to like results. As the aneurismal tumor enlarges, it presses more and more upon neighboring parts, giving rise to atrophy, ulceration, and interstitial absorption of parts, and occa- sioning a great variety of symptoms, according to the situation of the tumor, the organs and tissues influenced by it, and the amount and kind of pressure exerted on the textures concerned in the functions of nutri- tion and innervation. The treatment of aneurisms may be curative or palliative. The for- mer is carried out by the surgeon. The general treatment by Valsalva's method has already been alluded to (p. 614), and is now seldom practised. All the physician can do is to palliate symptoms, diminish the chances of rupture, and favor the obliteration of the enlarged vessel; to this end enjoining quietude, especially avoidance of sudden or long sustained 634 DISEASES OF THE CIRCULATORY SYSTEM. exertion. Occasional local and even general bleeding, topical applica- tions of ice or warmth as may be found most useful, and sedatives, tend to diminish pain. Constipation should be carefully guarded against, and healthy nutrition secured by attention to the various animal functions gentle exercise, etc. etc. DISEASES OF VEINS AND LYMPHATICS. Case CXXVIL*—Phlebitis of the Left Iliac Vein, supervening on Cancer of the Stomach and Oesophagus. History.—Alexander Henderson, aet. 23, baker—admitted June 22d, 1863. Pa- tient states that he has enjoyed good health, until about a year ago, whep he began to be troubled with heartburn. This annoyed him daily; and six weeks ago, half an hour after dinner, he vomited for the first time. Since then he has vomited every time he has taken food, and generally immediately on swallowing it, experiencing during the act of deglutition a feeling as if the bolus was obstructed in its passage to the stomach. Symptoms on Admission.—Tongue pale and clean in front, but loaded behind. No appetite. He vomits immediately upon swallowing food, except to-day when he has been able to retain a little beef-tea. Any bolus of solid food feels as if suddenly ob- structed in its course down the oesophagus, at a point about two or three inches to the left of the xiphoid cartilage, and this sensation is succeeded either by vomitino-, or by his distinctly feeling the bolus slip downwards into the stomach. He has constant pricking pain in the epigastric and left hypochondriac regions, which is increased by pressure, and greatest at the point where he feels the obstruction on swallowing. No tumor can be felt. Hepatic dulness 4\ inches. Bowels constipated. Cardiac impulse between 4th and 5th ribs, one-half inch internal to and below the nipple. Its dulness on percussion measures transversely 2\ inches.) A soft blowing murmur accompanies the first sound at the apex. Pulse 72, very weak. Frequent cough, with muco-purulent expectoration. The breathing over the whole back is somewhat harsh, and expiration is occasionally accompanied by sibilation. Considerably emaciated. Cheeks of a livid hue. Other functions normal. Progress of the Case.—The gastric symptoms of the patient were greatly alle- viated by careful arrangement of his diet, consisting of small quantities of unirritating food taken four or five times a day. The vomiting had ceased, and he was walking about the ward when, at 3 p.m., July 13th, he experienced a rigor, followed by febrile symptoms, and in the evening he complained of severe pain in the epigastric region, which was distended and tympanitic on percussion. Has no appetite. Face much flushed. Pulse 102, very weak. For some days previously he had noticed slight cedema of the ankles, for which diuretics had been ordered. July 14th.—The febrile symptoms diminished. Pulse 84, weak. July 16th.—Has had repeated shiverings during the day. Pulse 82, weak. Complains also of severe pains shooting down the left leg from the groin, and on examination, it is found to be greatly swollen, pitting very much on pressure. Some enlarged lymphatic glands can be felt in the left groin. The cedema of the right leg is much diminished. Urine passed during 24 hours, 20 oz., containing no albumen. A large warm poultice to be applied to the left groin. July 18th.—Continues to have occasional rigors followed by febrile symptoms. No appetite, ffidema of the legs the same as in last report, the left leg being greatly, while the right is but slightly, swollen. The pain in the left groin still continues. July 20th.—The cedema of the left leg is increasing, while there is now no swelling of the right. Still complains of great pain shooting down the left leg. Has no increase of appetite, but the feeling of obstruction on swallowing is now absent. Bowels which have been hitherto rather constipated, were moved last night by castor-oil. The abdo- men is distended with flatus. Pulse 118, weak, and occasionally intermittent. Urine, 22 oz. July 21st.—Last night had a rigor, and to-day at 2 p.m. he is found in a state of high fever, the face flushed, of a deep purple, and the tongue covered with a thick yellow fur, dry, cracked, and fissured. Pulse 130, very weak and intermittent. Still no appetite. Has no pain except when pressure is made over the left groin. Is verj * Reported by Mr. John Wylie, Clinical Clerk. DISEASES OF VEINS AND LYMPHATICS. 635 restless. No pulsation can be felt in the left groin, but there is induration and tender- ness on pressure. His bowels are opened regularly every second day by castor-oil. July 22d.—Lies on his back; his eyes fixed and glazed; his eyelids half closed. The tongue is still covered with the dry yellowish fur, and is protruded with great difficulty. Answers when spoken to and says he has very Uttle pain, but has some uneasiness about the epigastric region. Pulse 140, weak and intermittent. Pain and restlessness at night. R Chlorodyne nt xv.; Sp. JEth. Chlorici 3 ss; Mist. Camph. 3 vi. M. To be taken at bed-time. July 23d.—Last night was very restless, complaining of pain in the lower part of the back. Got the draught at 11 o'clock and became easier, but after midnight he was observed again to become restless, and at 4 o'clock this morning he died. Sectio Cadaveris.— Thirty-five hours after death. Body greatly emaciated, and very slightly jaundiced. Thorax.—The pericardium contains a considerable quantity of yellow serum. Heart.—Aortic valves competent. Mitral valve somewhat atheromatous. Lungs contain a few soft cancerous nodules of the size of marbles, dispersed in their substance. Abdomen.—Intestines greatly distended with flatus. Liver.—On making sections through the organ, it is found to contain a few cancerous masses, varying in size from a marble to a hen's egg. Stomach.—On opening into the stomach, its cardiac orifice as well as three inches of the lower part of the oesophagus, is found to be surrounded by hard scirrhous matter which is ulcerated on its internal surface. Pancreas healthy. In the Mesentery, especially near its root, there are a few scirrhous masses of the size of marbles. The left external iliac vein was greatly distended, and felt like a thick cord. On being opened, it was found to be occluded by a clot to the extent of four inches. The walls were one-eighth of an inch thick over this portion, and adherent to the clot. This was generally of a brick-red color, firm externally, but soft and pultaceous in the centre, where here and there it was of a fawn color. The smaller veins communicating with the altered vessel were also obstructed by clots. Other organs healthy. Microscopic Examination.—The harder part of the clot was composed of dense amorphous matter, and broken-down blood globules. The soft portions were composed of diffluent molecular fibrin, with a few colorless cells, resembling those of pus. Commentary.—In this man, who was weak and emaciated in con- sequence of cancer with stricture of the cardia, there occurs, without any obvious cause, intense fever followed by severe pain in the left groin, and cedema of the left inferior extremity. From this attack he never rallies, and dies ten days afterwards. On dissection, inflammation of the left iliac vein is found, its coats thickened and adherent to a clot which obstructed the vessel. The case offers another illustration of severe local inflammation occurring in weak emaciated subjects, which proves fatal from the want of vital power necessary for accommodating the system to the injury. Phlebitis, whenever it occurs, tends to cause obstruction of the vessels involved, and as a result of this, dropsy occurs. The object of treatment should be to support the strength until time has been given to establish a collateral circulation, which, if the patient be strong, and the case uncomplicated, frequently happens. But where, as in the instance before us, the strength is gone, from the results of gastric cancer, it could only hurry on the fatal termination. Case CXXVIIL*—Angio-Leucitis, supervening on Ritpia—Recovery. History.—John Mercer, set. 32, draper—admitted February 19th, 1859, with rupia, which followed primary and secondary syphilis that had been long treated with mercury. He has been of dissipated habits, and was in the house for delirium tremens. The whole skin is scattered over with prominent imbricated dark-brown scabs, varying m size from a small pea to that of a sixpence at the base. Other functions are normal. * Reported by Mr. R. T. Land, Clinical Clerk. 636 DISEASES OF THE CIRCULATORY SYSTEM. Five grs. of Iodide of Potassium to be taken three times daily. To have an alkalint bath. Progress op tbe Case.—Feb. 25th.—Last evening complained of pain on the flexor surfaces of both arms, extending from the wrist to the axilla. To day the pain is in- creased, and bright red lines, following the course of the lymphatics, may be seen ex- tending from the wrist, up the flexor surfaces, to the middle of both arms. The skin between them is erythematous. The tongue is furred; there is no appetite; consider- able thirst, but no rigor. Pulse 80, of good strength. Cloths steeped in warm water to be applied to both arms, and kept moist with gutta-percha sheeting. Feb. 26th.— Felt much relieved from the moist applications. Flexor surfaces of both arms were much indurated, but otherwise the same. Feb. 29th.—Last night at 12 o'clock had severe shivering which lasted till 2 a. m., with pain in the head, and general feverish symptoms. Both forearms are to-day more swollen and painful, the bright red lines feel like cords, and the erythematous redness is intensified and somewhat elevated above the surface of the skin. It may now be regarded as erysipelatous. Warm moist ap- plications to be continued. March 2d.—Yesterday the pain and swelling had greatly diminished, and to-day the whole has disappeared. The rupia also has greatly bene- fited from the moist apphcations, the scales have separated, and most of the ulcers have healed. April 2d.—Since last report has continued to do well, the rupia having nearly disappeared. Last night complained of pain on the inner side of the left knee, with slight erythema and swelling. Warm moist applications to be made to the part. This gave him great relief. The erythema, pain, and swelling continued, however, four days, and then diminished, without having especially affected the lymphatics. The rupia, also, is well, nothing remaining but the round and oval cicatrices. Dismissed April 11th. Commentary.—It is very possible that the irritation produced by the adherent crusts of rupia and the ulceration existing at their bases, may have been the exciting cause of the inflamed lymphatics in this case. No relation, however, could be observed between particular rupia crusts and the affected vessels. The general pain and local symptoms were very intense at one time, but yielded to warm moisture, applied locally, which caused great relief to the pain, while the disease ran its natural course. It is very rare that such a disease appears in the medical wards. The most remarkable case I ever saw of lymphatic disease, is one which has been recorded by Dr. A. Buchanan of Glasgow.* On examin- ing the affected thigh last September with that gentleman, the lymphatics appeared to me to be varicose, with vesicles scattered on the skin here and there, which, on being punctured, yielded an opaque milky fluid. Subsequently I received nearly half a pint of the chylous fluid from Dr. Buchanan, discharged from the lymphatics on the thigh of this woman, which, on microscopical examination, was composed of a mole- cular basis, with a few chyle corpuscles. * Med. Chir. Trans, of London, vol. xlvi. SECTION VII. DISEASES OF THE RESPIRATORY SYSTEM. In this, as in the preceding section, it will be well to introduce the study of individual diseases by a short enumeration of the general rules established for the diagnosis of lesions of the Respiratory System. They are— 1. A friction murmur heard over the pulmonary organs indicates pleuritic exudation. 2. Moist or dry rales, without dulness on percussion, or increased vocal resonance, indicate bronchitis, with or without fluid in the bronchi. 3. Dry rales accompanying prolonged expiration, with unusual reso- nance on percussion indicate emphysema. 4. A moist rale at the base of the lung, with dulness on percussion and increased vocal resonance indicates pneumonia. 5. Harshness of the inspiratory murmur, prolonged expiration, and increased vocal resonance confined to the apex of the lung, indicate in- cipient phthisis. 6. Moist rales, with dulness on percussion, and increased vocal reso- nance at the apex of the lung, indicate either advanced phthisis or pneu- monia. The latter lesion commencing at or^ confined to the apex is rare, and hence these signs are diagnostic of phthisis. 7. Circumscribed bronchophony or pectoriloquy, with cavernous dry or moist rale, indicates a cavity. This maybe dependent on tubercular ulceration, a gangrenous abscess, or a bronchial dilatation. The first is generally at the apex, and the two last about the centre of the lung. 8. Total absence of respiration indicates a collection of fluid or of air in the pleural cavity. In the former case there is diffused dulness, and in the latter diffused resonance on percussion. 9. Marked permanent dulness, with increased vocal resonance, and diminution or absence of respiration, may depend on chronic pleurisy, on thoracic aneurism, or on a cancerous tumor of the lung. The diag- nosis between these lesions must be determined by a careful consideration pf the concomitant signs and symptoms. The general diagnostic indications, now noticed as being derivable from physical signs, admit of several exceptions, which, however, it would be difficult to systematize, and which can only be known from a careful study of individual cases. It is important also to remember that 638 DISEASES OF THE RESPIRATORY SYSTEM. these signs should never be relied on alone, but be invariably combined with a minute observation of all the concomitant symptoms. Thus the signs indicative of incipient phthisis may be induced by a chronic pleurisy confined to the apex, or by retrograde tubercle. In either case the pre- vious histor*y, age, etc., may enable you to determine the nature of the lesion. Again, it may be impossible at the moment of examination to distinguish between two diseases. For instance there may be general fever, more or less embarrassment of the respiration, and pain in the side, accompanied with no dulness on percussion, but with a decided ab- normal murmur, difficult to characterise, as being a fine moist rattle, or a gentle friction sound. Under such circumstances, the progress of the case also will soon relieve you from any doubt as to whether a pleurisy or a pneumonia be present. The alterations which occur in the physical signs during the progress of the case also will indicate to the pathologist the changes which occur in the physical conditions and morbid lesions of the lungs. Thus the fugitive dry or mucous rales heard during a bronchitis, point out the occasional constrictions and obstructions in the bronchial tubes. The fine crepitation of incipient pneumonia, passing into absence of respiration, and this again into crepitation, will satisfy him as to effusion, solid coagulation, and subsequent softening of the ex- udation. In the same way, by an accurate appreciation of physical signs, and a thorough knowledge of morbid anatomy, the practised physician can tell the abnormal conditions produced by phthisis, pleurisy, etc., and judge from the symptoms the effect of these upon the constitution, with a degree of accuracy that to the tyro must appear to be marvellous. All such knowledge can only be acquired by constant examination of the patient on the one hand, and by a careful study of morbid anatomy in the pathological theatre on the other. DISEASES OF THE LARYNX. Case CXXIX.*—Acute Laryngitis—Treated by Topical Applications— Recovery. History.—Alexander Flint, aet. 27, a salesman—admitted February 17, 1851, suffering from extensive lupus of the face, severe diarrhoea, Bright's disease, and scro- fulous caries of the left knee-joint. Under appropriate treatment the diarrhoea ceased, the lupus was cured, and the disease of the kidney much alleviated. Symptoms of the Attack.—On the 24th of May, about three months after admis- sion, he first complained of dry cough and slight pain in the throat, with difficulty of deglutition. These symptoms were increased on the following day; and on examina- tion the mouth and fauces were unusually red, with minute florid elevations scattered over the mucous surface. Notwithstanding the application of leeches, and sponging the fauces with a solution of the nitrate of silver, the laryngitis progressed. Progress op the Case.—On the 14th of June the pain and difficulty of deglu- tition had increased, and his voice had become indistinct and hoarse. The cough also continued, but was now attended with a difficult expectoration of muco-purulent matter. On the 30th of June, notwithstanding the assiduous use of astringent gargles, occasional sponging of the fauces with solution of nitrate of silver, and the application of leeches, he was evidently worse, and he could only speak in a whisper. July 6th.—To-day Dr. Horace Green, of New York, who went round the wards with * Reported by Mr. W. M. Calder, Clinical Clerk. DISEASES OF THE LARYNX. fi:lfl Dr. Bennett, stated that this was a remarkably good example of what he had named follicular disease, affecting the larynx. He passed the sponge, saturated with a solu- tion of nitrate of silver (3ij to § i of water), through the larynx into the trachea. The patient could not take a breath for some seconds afterwards, and described the sensation as like that produced by a piece of food " passing down the wrong way, and causing choking." The immediate effect of the operation was decided improvement of the voice, and more ease in deglutition. From this time his symptoms gradually left him. On the 10th, the sponge was again passed into the larynx by Dr. Bennett, and produced the same sense of temporary suffocation; but immediately afterwards he spoke with perfect clearness of voice. The application was made every second day until the 16th, when all the laryngeal symptoms had disappeared, the voice was nor- mal, and there was no cough, expectoration, pain, or difficulty of deglutition. He now left the house; the disease in the joint had made considerable progress, but the renal disorder was much alleviated. Case CXXX.*—Chronic Laryngitis—Topical Applications—Recovery. History.—Helen Guthrie, aet. 24, married, a fisherwoman—admitted July 4th, 1851. Four months ago was seized with a cough, attended with hoarseness of the voice, dryness of the throat, painful deglutition, and pain in the larynx, which symp- toms have continued with greater or less intensity up to the period of admission. Lat- terly, there has been considerable expectoration of purulent matter, often tinged with blood. Symptoms on Admission.—On admission, she complains of cough coming on in paroxysms, dryness in the throat, and pain in the larynx, voice cracked and occa- sionally absent. There is no difficulty in swallowing, but copious expectoration of frothy mucus. Can inspire without difficulty. Percussion over chest elicits nothing abnormal. On auscultation, the inspiratory murmur is harsh over superior third of chest on both sides. Over larynx and trachea there is heard a dry snoring sound. On examining the fauces, red patches were observable here and there, with slight erosion on the left side. The fauces and epiglottis were sponged with a solution oi nitrate of silver ( 3 j to § j of water). Progress of the Case.—The application was repeated on the following day, and the voice was evidently improved. On the 6th, the sponge, saturated with the solu- tion, was passed into the larynx by Dr. Horace Green, of New York, and produced no feeling of suffocation whatever. It was passed afterwards every day by Dr. Ben- nett till the 14th, when she left the house, all the laryngeal symptoms having disap- peared, and the voice nearly restored to its proper tone. Commentary.—The two cases above recorded point out to you in a very marked manner the great advantage to be derived from the method of local application to the larynx, introduced by Dr. Horace Green, of New York. This practice consists in the direct application of a solution of nitrate of silver to the interior of the larynx and trachea, by means of a bent whalebone probe, with a piece of sponge fastened to its extremity. Numerous attempts had been made, with more or less success, by Sir C. Bell, Mr. Vance, Mr. Cusack, and MM. Trousseau and Belloc, to carry this practice into effect, and the results obtained, even by their imperfect efforts, exhibited the great advantages which were to be derived from it in the treatment of laryngeal diseases. Now, thanks to Dr. Green, we can with safety apply various solutions directly to the parts affected, and the two cases you have observed must convince you of the benefit which patients so treated may obtain. In Case CXXIX. you have observed the progress of a tolerably acute case of laryngitis from its commencement to its termination—the distressing symptoms produced, and the loss of voice occasioned. You have re- marked, I trust, the gradual increase of the disorder, from its commence- * Reported by Mr. D. 0. Hoile, Clinical Clerk. 640 DISEASES OF THE RESPIRATORY SYSTEM. ment on the 24th of May until the 6th of July, when you saw Dr- Green himself pass the sponge into the larynx, and the immediate effect it occasioned. Lastly, from that moment you saw the case get better, and terminate in perfect cure eight days afterwards. No stronger evidence could be offered you in any single case of the benefit to be derived from a local application, especially when it is considered that the usual treatment had been actively employed, consisting of leeches externally, gargles, and the application of a strong solution of nitrate of silver to the fauces, pharynx, and epiglottis without any benefit. It was only when the application was made directly to the part affected that good was obtained. The second case, though more chronic, and though she went out before a perfect cure was obtained, is also calculated to impress upon you the value of this treatment. The instruments to be employed are, first, a tongue depressor, with a bent handle, such as I now show you (Figs. 4 and 5), by means of which the tongue can be firmly pressed down, so as to expose the whole of the fauces, and the upper edge of the epiglottis. In doing this, some patients experience no inconvenience, whilst in others there is such excessive irritability, that spasmodic cough or even vomiting is occasioned,. which prevents the possibility of seeing the epiglottis. Secondly, a whalebone probang, about ten inches long, having at its extremity a round piece of the finest sponge, about the size of a gun or pistol bullet. ,The probang, towards the extremity, must be bent in a curve, which, according to Dr. Green, ought to form the arc of one quarter of a circle whose diameter is four inches. Sometimes the curve must be altered to suit particular cases; and when it is thought necessary to pass it into the trachea, the curve must be considerably less. It is important that the sponge be fine, and capable of imbibing a considerable quantity of fluid; that it be sewn firmly to the extremity of the whalebone, and that this last should not be cut in the form of a bulb, but tapered as much as consistent with firmness. The solutions of the nitrate of silver which will be found most use- ful are of two strengths. One is formed of 3ij and the other 3 j of the crystallized salt to an ounce of distilled water. On some occasions a solution of the sulphate of copper has been found beneficial, and it is very possible that as our experience of this kind of treatment extends, the application of other substances in solution may be found capable of meeting parti- cular indications. Some have used Tr. of Iodine, others solutions of various salts, and Dr. Scott Alison, in cases of great irritability, has re- commended olive oil. The method of introducing the sponge which I have found most successful is as follows :—The patient being seated in a chair and exposed to a good light, you should stand on his right side, and depress the tongue with the depressor held in the left hand. Holding the probang in the right hand, the sponge having been saturated in the solution, you pass it carefully over the upper surface of the instrument, exactly in the median plane, until it is above or immediately behind the epiglottis. You now tell the patient to inspire, and as he does so, you drag the tongue slightly forwards with the depressor, and thrust the probang down- wards and forwards by a movement which causes you to elevate the right DISEASES OF THE LARYNX. 641 arm, and brings your hand almost in contact with the patient's face. This operation requires more dexterity than may at first be supposed. The rima glottidis is narrow, and unless the sponge come fairly down upon it, it readily slips into the oesophagus. Its passage into the proper channel may be determined by the sensation of overcoming a constric- tion, which you yourself experience when the sponge is momentarily em- braced by the rima, as well as by the momentary spasm it occasions in the patient, or the harsh expiration which follows,—symptoms which are more marked according to the sensibility of the parts. If the probang be properly prepared, and the operation well per- formed, the actions which take place are as follows :—1st, The sponge, saturated with the solution, is rapidly thrust through the rima into the larynx, and frequently into the trachea ; for if the distance of the pro- bang be measured from that portion of it which comes in contact with the lips, the extent it has been thrust downwards can be pretty accu- rately determined. I am persuaded that on many occasions I have pass- ed it pretty deep into the trachea, not only from the length of the pro- bang which has disappeared, but also from the sensations of the patient, although this may be thought by some a fallacious method of determin- ing the point. In the first part of the operation, the rima glottidis is, as it were, taken by surprise, and the sponge enters, if the right direc- tion be given to it, without difficulty. But 2d, The rima glottidis im- mediately contracts by reflex action, so that on withdrawing the instru- ment you feel the constriction. This also squeezes out the solution, which is diffused over the laryngeal and tracheal mucous membrane. Now, if the sponge be a fine one, it will be found capable of holding about 3 ss of fluid, the effect of which upon the secretions and mucous surface almost always produces temporary relief to the symptoms, and strengthens the tone of the voice—results at once apparent after the momentary spasm has abated. 3d. The action of the nitrate of silver solution is not that of a stimulant, but rather that of a calmative or sedative. It acts chemically on the mucus, pus, or other albuminous fluids it comes in contact with, throws down a copious white precipitate, in the form of a molecular membrane, which defends for a time the ten- der mucous surface or irritable ulcer, and leaves the passage free for the acts of respiration. Hence arises the feeling of relief almost always occasioned, with that diminution of irritability in the parts which is so favorable to cure, and why it is that strong solutions of the salt are more efficacious than weak ones. It may be easily conceived that such good effects must be more or less advantageous in almost all the diseases that affect parts so sensitive, from whatever cause they may arise; and that this treatment is not only adapted to one of the diseases of the larynx, but, like all important remedies, meets a general indication of which the judicious practitioner will know how to avail himself. The mucous membrane of the larynx consists of ciliated epithelium externally, a basement layer below this, and areolar tissue internally, richly supplied with blood-vessels. Scattered over its surface are numerous follicles, which secrete mucus. It is liable to the same structural alterations as all other similar membranes, which may be 41 642 DISEASES OF THE RESPIRATORY SYSTEM. divided into—1st, Exudation, into the areolar tissue between the base- ment membrane and epithelium, or upon the external surface; 2d Abrasions or desquamations of the epithelial layer ; 3d, Ulcerations ex- tending more or less deep into the areolar tissue ; and 4th, Obstruction swelling, and subsequent ulceration of the mucous follicles, a lesion particularly described by Dr. Horace Green, and denominated by him " follicular disease of the air passages." These different lesions may be more or less complicated with each other, and will vary in intensity ac- cording to the rapidity of their progress, and the extent to which the mucous membrane is implicated. Sometimes the exudation is thrown out quickly and infiltrates the textures, as in cedema glottidis, or in malignant angina. At other times it is poured out on the surface as in croup. More frequently it is partial, occasioning subsequent abrasion or ulceration, and the acute disease becomes chronic. Perhaps the most common form it assumes is when it is chronic from the commencement, sometimes dependent on atmospheric changes, at other times on re- peated attacks of "cold;" in a third class dependent on too much straining of voice, as occurs in public speakers, clergymen, singers, etc., and occasionally it is connected with a general constitutional disorder, as syphilis, tuberculosis, or some form of cancer. All these forms of laryngeal disease may be further associated with similar lesions of the fauces, tonsils, uvula, and pharynx. The symptoms will of course vary according to these different cir- cumstances. The acute forms are accompanied with general fever, con- siderable local pain, more or less obstruction to deglutition and respira- tion, and loss or alteration in the character of the voice. As a general rule, it may be said that lesions of the fauces, tonsils, and neighboring parts, are indicated by greater or less difficulty or uneasiness in swallow- ing, whilst the laryngeal disorder is evinced by changes in the character or power of sustaining the voice. Then, as a general result of the local irritation, spasmodic action is evinced, and we have cough, at first dry, but afterwards attended with mucous or purulent expectoration, and not unfrequently with discharge of blood. Elongation of the uvula may produce these effects. It has been lately supposed that hooping-cough is only an obscure form of laryngeal disease. In the more acute and ex- tensive cases of exudative laryngitis, the spasms are more violent and prolonged, and the greatest caution is necessary in watching persons so affected, lest, from sudden and continued closure of the glottis, fatal asphyxia be induced. The following case is very instructive in this point of view. Case CXXXL*—Acute CEdema of the Glottis—Chronic Pharyngitis and Laryngitis—Sudden Death. History.—Frances Nichol, aet. 25, a shoe-binder, married—was admitted in the evening of February 27, 1851, complaining of sore throat, but breathing easily, and otherwise presenting no urgent symptoms. She has suffered from cough upwards of four years, had secondary syphilis, and ulcerations in the throat for twelve months. Symptoms on Admission.—At the visit I found her breathing to be laborious and noisy; cough frequent; expectoration difficult, with frothy sputum tinged with blood; * Reported by Mr. Henry Thorn, Clinical Clerk. DISEASES OF THE LARYNX. 643 countenance anxious ; lips livid; pulse 130, small and soft; cannot speak, nor can any one give any account of her. On examining the mouth and fauces, the mucous membrane was seen to be covered with tenacious muco-purulent matter. The soft pa- late is perforated by ulcerations the size of a pea in three places; there is another ulcer the size of a fourpenny piece on the roof of the mouth. The tonsils and mucous membrane surrounding the glottis were somewhat swollen, but not unusually red. On percussing the chest, no dulness could anywhere be detected. Respiratory mur- murs over the large air-tubes loud and harsh, with occasional mucous rale, but their character masked by the loud snoring noise in the larynx. To have 3 ss of wine every half-hour ; an antispasmodic mixture of sulphuric ether, ammonia, and opium ; the ulcers and mucous membrane of the fauces to be sponged with a weak solution of nitrate of silver, and the steam inhaler to be used assiduously. Progress of the Case.—These remedies alleviated all her symptoms, so that in the evening she gave a history of her case. Seeing that she was so much better at the evening visit of the house-clerk, the intensity of the disease was supposed to have abated, but in the morning she was found dead in bed. Sectio Cadaveris.—Fifty hours after death. Pharynx, Larynx, and Trachea.—The opening of the fauces was considerably contracted; and the mucous membrane of the tonsils, soft palate, and from this to the root of the tongue, presented numerous ulcerations, extending to the submucous tis- sue, and undermining to some extent the mucous membrane. The ulcers were mostly rounded in form, of exceedingly various size, up to a diameter of three-eighths of an inch ; the edges not at all elevated, and for the most part smooth, as though scooped out by a punch. The floors of the ulcers consisted of the submucous tissue, perfectly clean and pale, without the least trace of granulation or pus. The neighboring mu- cous membrane was scarcely at any point more vascular than natural. The aryteno- epiglottidean folds were hypertrophied,—that of the right side being thickened and oedematous, that of the left being flaccid and relaxed. They could be made to lie in apposition, so as almost to close the opening of tho glottis. The mucous membrane of the entire larynx was somewhat ross-colored ; and the submucous tissue of the epiglottis, the chordae vocales, and the ventricles, cDnsiderably infiltrated with fluid. Throughout the trachea, the membrane was of a rose color, becoming deeper towards the bronchi, and was everywhere covered with a thick mucus, which lay in semi-trans- parent drops, the size of a very small pin's head, on the opening of the follicles. Thorax.—The tissue of the lungs was. for the most part healthy, but here and there a few small portions of its substance were collapsed. The mucous membrane of the larger bronchi was congested, and the smaller ones on the right side yielded drops of purulent mucus, on compressing the cut surface of the lung. Abdomen.—There were several small cancerous nodules in the liver, but all the organs were healthy. Commentary.—In this case I think there can be little doubt that during the night some obstruction occurred to the breathing, dependent on the local disease, which caused asphyxia and death. Neither can we have any hesitation in thinking, that had tracheotomy been performed in time, life would have been saved, inasmuch as the tissue of the lungs was healthy, and the only lesion found in those organs was a trifling bronchitis. No doubt the amelioration of the symptoms which was observed at the evening visit removed the idea of urgency, but this is just the reason I have cited the case, as a lesson to all of us, with regard to the watchfulness which is necessary in the treatment of such disorders. In another case, occurring in a man who entered the clinical ward shortly afterwards, laboring under symptoms so similar that I need not detail them, I ordered tracheotomy to be performed at once, and the result was the preservation of life and restoration to health, although the ulceration destroyed the vocal chords, and the aphonia was complete. The following case presents the most rapid progress of acute laryngitis I ever saw, and points out strongly the necessity of great watchfulness in this disease. 644 DISEASES OF THE RESPIRATORY SYSTEM. Case CXXXIL*—Acute Laryngitis supervening on Ascites, and Cirrhosis of Liver—Sudden Death from Asphyxia. History.—William Corbett, ast. 40, seaman—admitted October 4th, I860 with enlarged liver and ascites. Symptoms on Admission.—The liver, on percussion, measures six inches vertically and the abdomen is greatly distended. Urine passed daily only 19 oz. The treatment was directed, by means of diuretics, to increase the flow of urine, and Tr. of Iodine was ordered to be painted over the hepatic region. Progress of the Case.—October 29th.—Has been taking half-drachm doses of the bitartrate of potass, with the effect of increasing the flow of urine to 40 and 45 oz daily. To-day complains of pain in swallowing, and says he has had cough for the last two nights. The fauces on examination are somewhat congested. The throat to be fomented, and a warm poultice to be applied at night. October 31st.—Has experienced much relief from the warm applications, and swallows without much inconvenience. He expectorates, however, after coughing, a frothy, slightly viscous mucus. November Is;.—Cough very troublesome during the night. Expectorated about 6 oz. of frothy mucus since yesterday. Tongue covered with a brown fur. Pulse accelerated, but no fever. Abdominal symptoms and signs unchanged. Passes 45 oz. of urine daily. R Chlorodyne 3 ss; Mist. Camph. § ij. Half to be taken at bed-time, and repeated in the night if the cough be troublesome. Warm poultices to the throat to be continued. November 2d.—Cough and expectoration very troublesome last night, preventing sleep, notwithstanding the anodyne. Sputum frothy, slightly purulent. Voice slightly hoarse. On examining throat, fauces seem to be very red, and tonsils swollen. Other symptoms the same. To use an astringent alum gargle. Continue fomentations and poultices to the throat. November 3d.—According to the reports of the night nurse, he became restless, constantly requiring attention about the middle of the night, with difficulty of breathing. She did not observe anything very urgent, however, un- til 6 a.m. this morning, when she went for the house physician. No sooner had she left his bedside, than he rose, fell down, and on being raised by two neighboring pa tients, gave one gasp and expired. Sectio Cadaveris.—Thirty hours after death. Considerable lividity of lips, face, and neck. Fauces and Larynx.—Fauces everywhere greatly congested. Left tonsil much swollen, and the circumvallate villi at the base of the tongue numerous, enlarged, and prominent. The epiglottis thickened, indurated, and erect, of deep purple color, con- ical form, with its external edges curved inwards. The neighboring mucous mem- brane thickened and infiltrated with exudation. On opening the trachea and larynx from behind, the mucous membrane was seen to be of a deep mahogany uniform color from congestion; both vocal chords, true and false, on each side were infiltrated with exudation. The right ventricle was occupied by, and distended with, a straw-colored mass of coagulated exudation f of an inch long, and \ of an inch broad at its widest part, bulging inwards towards the rima glottidis. The mucous membrane surround ing left ventricle, oedematous, indurated, and an oval mass of coagulated exudation i of an inch long, blocking up the left ventricle, bulging inwards and obstructing the rima glottidis. Chest.—About an ounce of serum in the pericardium, none in the pleural cavities. Heart healthy, cavities empty. No congestion of right side of heart. Lungs of dark mahogany color throughout; bronchial lining membrane also of dark mahogany color, and towards bases of both lungs posteriorly the bronchi contained a slight amount of frothy mucus. Abdomen.—Liver enlarged, weighing 6 lb. 2 oz., of a pale fawn color, considerably indurated, in the second stage of cirrhosis. Abdomen contained two gallons and a half of amber-colored serum. Other organs healthy. Microscopic Examination.—The lymph filling up the ventricles of the larynx was entirely composed of molecular fibres, included in a mass of coagulated molecular exudation. Commentary.—This man, while laboring under enlarged liver with ascites, was apparently seized with an ordinary sore throat, having caught cold, as it was afterwards ascertained, when visiting the water-closet. * Recorded by Mr. James Pettigrew, Clinical Clerk. DISEASES OF THE LARYNX. 645 There were no severe symptoms, however, farther than cough, expectora- tion, and slight difficulty of deglutition, which latter symptom yielded to warm fomentations and poultices applied to the throat. On the morning before his death, the voice was somewhat hoarse, which was the first symptom indicating that the larynx was affected. Neither at the visit, Fig. 448. nor in the evening when seen by the house physician, nor by the nurse, were any urgent symptoms observed, until about the middle of the night. Then suddenly respiration became affected, he was restless, and dyspncea came on so rapidly, that before medical assistance could be procured, he expired on making the exertion of rising from bed. I have previously pointed out how insidiously fatal laryngitis may come on, and how rapid Fig. 448. Appearances described in the case of Corbett—Natural sice. 646 DISEASES OF THE RESPIRATORY SYSTEM. its effects occasionally are. It is certain that no acute symptoms indi- cated danger at the morning or evening visit, the man speaking on both occasions, and that day for the first time somewhat hoarsely. There can therefore be little doubt that it was in the middle of the night that the exudation must have occurred into the ventricles of the larynx, which bv closing the glottis, caused the fatal asphyxia. The appearances observed were so striking that they are represented Pig. 448. Case CXXXIIL*—Chronic Larynyitis and Pharyngitis— Tracheotomy—Recovery. History.—Hugh Martin, set. 35, laborer—admitted December 28th, 1849. Says chat six years ago, he had gonorrhoea, without any other form of venereal affection! Twelve months since, he was treated with calomel for some swellings below his jaw, and shortly after, having caught cold, was affected with sore throat. Subsequently he was again treated with mercury in the Glasgow infirmary, and having again caught cold, his throat became worse. Symptoms on Admission.—His general appearance is cachectic and emaciated. His speech is almost inaudible, and the upper part of a large ulcer is seen deep down in the pharynx. Respiration is evidently impeded and accompanied by hoarse tubular breathing, heard on placing a stethoscope over the larynx. Pulmonary sounds feeble, and resonance good everywhere on percussion over the lungs. Has slight cough with muco-purulent expectoration, not so copious, he says, as it has been. Has pain in deglutition, which often excites violent cough. Pulse 82, of natural strength. Other functions well performed. The urine contains hexagonal plates of cystine, miDgled with crystals of uric acid. Progress of the Cape.—December 30th.—Topical applications of a weak solution of nitrate of silver internally, and warm fomentations to the throat externally, have failed to cause relief. Breathing still impeded and difficult; voice extinct. Tracheo- tomy was performed, and a tube inserted. January 11th.—Since the operation, he has breathed freely through the tube, and feels much easier. The ulcer in the pharynx has been touched occasionally with nitrate of silver, and is now healed. Has con- siderable difficulty in expectorating mucus through the tube. To have steak diet. Dec. 20lh.—A solution of nitrate of silver (2 gr. to §j of water) to be applied to the inside of the trachea every other day, by means of a sponge attached to a slip of bent whalebone. Dec. 23d.—Has been greatly relieved by the topical application to the trachea. Strength of solution to be increased to Argent. Nit. gr. v. to § j water, and applied daily. December 26th.—Strength of solution further increased to gr. x. of the salt to zjof water. From this time, the muco-purulent expectoration gradually subsided. R Potass. lodid. 3 ss; Tr. Gent. c. § j ; Inf. Gent. c. § v. M. j to be taken three times a day. February 10th.—The tube was removed. The voice returned, although it re- mained very hoarse, and there was every reason to believe that the ulcer in the larynx, if not perfectly cicatrized, was nearly so, when he went out, February 20th, Commentary.—In this case tracheotomy was performed, not so much with the view of relieving urgent symptoms, as to secure rest and immobility to the larynx, so that the ulcerations might cicatrize. This object was effected, and the man slowly got well. First, the ulcer in the pharynx healed, and subsequently that in the larynx, although, when the tube was removed from the trachea, it was apparent that the vocal chords had been partially destroyed. At the time this case was treated, the mode of application by means of sponges to the interior of the larynx was unknown. The record shows, however, that in 1849 I applied a nitrate of silver solution directly to the trachea, through the aperture made for the tube, which was from time to time removed for that pur- pose. I then found its use very beneficial in checking the amount of muco-purulent secretion, and increased the strength of the solution from * Reported by Mr. Hugh M. Balfour, Clinical Clerk. DISEASES OF THE LARYNX. 647 two to ten grains of the salt to an ounce of water. The man complained of no pain or inconvenience of any kind from these applications. He had undergone two courses of mercury, and so far as his own statements are to be relied on, without any other form of venereal disease than that of gonorrhoea, and swellings below the jaw. Even supposing that these latter were originally venereal, it is certain that the mercury produced no benefit, but, on the contrary, while the local disease was making pro- gress, it so affected his general health, as to occasion emaciation and general cachexia. We have seen that the ulcers healed under a non- mercurial treatment, and that his health improved under tonics and good diet. The diagnosis of laryngitis is most important, and must be derived— 1st, From the general symptoms; 2d, From the results obtained by careful examination of the air-tubes and lungs by auscultation and per- cussion ; and 3d, From an inspection of the parts. With regard to the general symptoms, I have already alluded to the relative value to be attached to difficulties of deglutition and of speech. Concerning the difficulties of respiration, the nature of the expectoration, and the cough, we cannot with certainty refer them to the larynx, without a careful study of the condition of the pulmonary organs. Indeed, the attention which has been lately directed to the fauces and larynx, in consequence of the writings of Dr. Horace Green, has demonstrated the important fact, that many of those disorders which have been sometimes called " chronic bronchitis," and others which have not unfrequently been sup- posed to indicate in'young persons incipient phthisis, are really a chronic form of laryngitis, altogether local, and readily removed by topical ap- plications. The distinction between them, however, often demands the greatest care in examination, but when a yood auscidtator fails to detect the signs characteristic of bronchitis or phthisis pulmonalis, whilst, on the other hand, there is unusual hoarseness or shrillness of the laryngeal murmur, dryness of the throat, and hacking cough, sometimes accom- panied by muco-purulent expectoration, or even occasional spitting of blood, then his suspicions may be directed to laryngeal rather than to pulmonary disorder. It is the more important to notice this, because a good authority has lately stated,—" Expectoration of blood in persons laboring under chronic bronchitis, with or without emphysema, but without notable disease of the heart, justifies in itself a suspicion of the existence of latent tubercles." — (Walshe.) In making this diagnosis, however, I must recommend to you the exercise of the greatest caution, and especially not to confound the natural hoarseness heard in the larynx of some individuals with the coarse sounds heard in others only when the organ is diseased. The examination of the throat and upper edge of the epiglottis will do much to remove any difficulty you may experience, because in many cases alterations in the mucous membrane of the larynx follow and accompany similar changes in the mucous membrane of the fauces and pharynx. Indeed, it may be accepted as a general law, which admits of but few exceptions, that morbid changes in the mucous membranes of the pharynx and larynx proceed from above downwards, as is well ob- 648 DISEASES OF THE RESPIRATORY SYSTEM. served in scarlatina. Lesions often attack the fauces or tonsils and spare the larynx; but if long continued, the latter is affected consecutively, Hence why chronic, syphilitic, and mercurial ulcerations of the throat, have such a tendency to attack the larynx. Again, when the larynx is first attacked, as occurs among clergymen, and in the ordinary croup of children, the follicular disease in the one, and the coagulated exudation in the other, tend to pass down the trachea, and not upwards into the fauces. It follows, that when hoarseness of the voice, cough, and other laryngeal symptoms are accompanied by abrasions or ulcerations in the mucous membrane of the soft palate or uvula, by thickening or irregu- larity in the epiglottis, and especially by the follicular disease formerly alluded to—presenting elevated pimples more or less numerous scattered over the parts—there is every reason to believe that the larynx is simi- larly affected. The tongue-depressor previously alluded to will enable you to examine these parts with the greatest ease, and in most cases the upper edge of the epiglottis will with its aid be brought into view. In this manner we receive exact information as to the state of the fauces, uvula, tonsils, and back of the pharynx, but valuable as such informa- mation is, we cannot determine by it the condition of the glottis. Occa- sionally, under such circumstances, the finger will assist us and enable us to feel swelling, induration, or irregularity in the epiglottis. But to derive information in this manner, tact and habit are necessary. The introduction of the laryngoscope has been too recent, and the cases which have presented themselves during the limited period I have been on duty, have been too few, to enable me to say much as to the advan- tage of the instrument as a means of diagnosis. I consider, however, that its employment should be vigorously prosecuted, although in acute cases I have found the pain and irritability of the parts oppose an in- vincible obstacle to my bringing the organ into view. In no case ought you to depend upon examination of the parts alone; it should be con- joined with the knowledge derived from a careful study of the symptoms, and of the physical signs furnished by the air-tubes and lungs. Two other diseases, by causing obstruction of the larynx, are justly regarded with great apprehension; these are tracheitis or croup, and diphtheria. In both these diseases an exudation is thrown out on the mucous membrane, which, coagulating and blocking up the chink of the glottis, proves fatal. Neither of these diseases are common in the clinical wards. Indeed, I have only seen one case of diphtheria here, and that was in a man called Carrall, who died in November 1860, affected with small-pox, violent fever, and a sore throat, which was covered with a dirty grey exudation. In the foundling and chil- dren's hospitals of Paris I have frequently seen it, where it presents a tough, adherent membrane, in which vegetable parasitic growths are abun- dant. (See Fig. 53.) All these various affections pass insensibly into one another; so that, with that natural exaggeration so common to anxious relatives, slight interruption of the respiration, owing to enlarged tonsils, is frequently regarded as croup, whilst almost every severe case of sore throat is now denominated diphtheria. In true cases of croup and diphtheria, however, with febrile symp- toms and the unequivocal formation of a false membrane on the mucous DISEASES OF THE LARYNX. 649 membrane invading the glottis, the greatest danger is to be apprehended. In croup, emetics are useful; and occasionally a few leeches applied over the sternum, I have seen act like a charm. Observe that when applied, they must be placed carefully over the bone, so that the hemorrhage may afterwards be commanded by slight pressure; for if placed on the throat or soft parts, as has occasionally been done through inadvertence, the danger and inconvenience afterwards is very great. If suffocation be threatened, the sooner tracheotomy be performed the better, for although that operation is far from being always successful, and is not unattended with danger, the risk from the disease I hold to be much greater. Dr. J. Buchanan of Glasgow has recently published an account of twenty-one cases of diphtheria, all of which were on the point of suffocation when the operation was performed, with the result of causing recovery in seven. In all these cases I regard the mode of applying topical remedies introduced by Dr. Green as a most valuable addition to our other means of cure. The experience of that physician indicates, that the earlier it is applied the greater the chance of success, especially in acute cases of scarlatina and croup. It was first applied in hooping-cough by Dr. E. Watson of Glasgow, and has subsequently been tried in laryngismus stridulus, hay fever, and other diseases hitherto considered spasmodic, and with such success, as to lead to the conclusion that these disorders are essentially connected with local irritations or an obscure form of catarrh. In various kinds of laryngeal disease occurring in the adult, whether primary or secondary, I have employed it very extensively, in many instances with permanent good results, and in a large number with temporary alleviation. Indeed, nothing is more remarkable than the immediate effect it has in clearing the throat and improving the tone of the voice, and hence, in many cases which do not admit of cure, it may be employed as a palliative. As such, I have successfully used it in old cases of chronic laryngitis and bronchitis, clergyman's sore throat, spasmodic asthma with accumulation of mucus in the trachea, and so on. In syphilitic and confirmed tubercular laryngitis, though not so bene- ficial, it is still in some cases decidedly useful. I have, however, met with several instances where it has been very injudiciously employed, and others where the sponge had been passed by unskilful hands re- peatedly down the oesophagus without any good effect, the patient having been persuaded for a considerable period that it had been applied to the larynx. Circumstances of this kind may bring the practice into dis- repute with some, but I trust you will discriminate, and neither lightly abandon it from a few failures, nor be led into the opposite error, of supposing, from one or two favorable cases, that it is capable of being invariably successful. Case CXXXIV.*—Pertussis— Violent Paroxysms—Rronehitis—Collapse of the Lungs—Recovery. History.—Wilham Campbell, aet. 4\—admitted 18th June 1864. The mother first noticed a cough in this child two weeks ago, which was accompanied by a distinct whoop. About the same time he vomited a good deal of mucus at the close of cough- * Reported by Mr. H. S. Pavson, Clinical Clerk. 650 DISEASES OF THE RESPIRATORY SYSTEM. ing, which seemed to give him great relief. She knows no cause for the disease, except that, for a few fine days previous to the commencement of the cough, the child played out of doors without shoes. Symptoms on Admission.—A strong, vigorous child. Respirations 68 per minute. Inspiration hurried. Percussion anteriorly normal. Sibilant and sonorous rales heard on both sides of chest. Posteriorly percussion normal. Sibilant and sonorous rales heard, with mucous rales over both bases of lung, with inspiration and expiration. Expectoration copious, nummular. Pulse 144, regular, but feeble. Tongue covered with a slight white fur—oedematous. Bowels regular. Stools natural. Skin moist. Patient emaciated. Other functions normal. Progress of the Case.—June 19th.—Slept well last night, but had two or three fits of coughing. Expectorates large quantities of mucus. Took his breakfast this morning. Had several paroxysms of coughing at the visit, with the whoop so loud as to be heard not only over the ward, but in the neighboring passages. The congestion and lividity of the face, scalp, and neck, were well marked. He generally feels hungry after each paroxysm, and asks for something to eat. Dyspnoea continues. Pulse 150. Skin hot and dry. Had three stools to-day. Urine amber-colored; sp. gr. 1022; acid reaction; otherwise normal. R Acid. Nit. DU. § j; Tr. Cardam. Co. § ss; Syrupi § ivss. M. Sig a dessert-spoonful to be given every four hours. 24th.—Has continued the same, but on examining the chest anteriorly slight comparative dulness on right side inferiorly; breathing tubular and harsh, with a few mucous rales. On left side, loud vesicular breathing, with abundant mucous rales. Posteriorly, dulness on percussion in lower third of right, and in lower fourth of left back. Percussion otherwise normal. At right base, breathing tubular, with clicking mucous rales; higher up, breathing feebly tubular, mixed with vesicular breathing. On left side, breath sounds normal. Urine deposits lithates. 25th.—Cough increased. Takes food as usual. Tongue clean. Bowels regular. Vomited after tea, in consequence of a fit of coughing. Pulmonary signs as yesterday. Sputum as on admission, only not nummular. Ordered a linseed poultice, with mustard on it, to be applied to the right side of the chest for ten minutes. Urine still loaded with lithates. Continues to take the acid mixture. 26th.—No change. The acid mixture has been taken regularly, but appears to produce no effect on the disease. Ordered Linimentum Terebinthina; Ace- ticum (Ph. B.), to be rubbed over back and front of the chest twice a day, especially over right side. 28th.—Pulse 180, regular. Respirations 80 per minute. Tongue clean. Bowels regular. Breathing rather troublesome. Skin warm and moist. To discon- tinue Acid Mixture, and to have Sherry wine § ii daily. 29th.—Slept pretty well last night. Took some bread and milk for breakfast. Had several paroxysms of cough during the night, but did not vomit. Vespere.—Was asleep at visit, but had a loud wheezing noise in his chest. Respirations hurried (68 per minute). Took some broth and meat for dinner. R Acidi Hydrocyan. DU. ulxvi; Syrupi Simplieis 3 ss; Aquoe Mentha; Pip. § iiiss. M. Fiat mistura. A tea-spoonful to be taken every second hour. He now slowly recovered, and was dismissed July 29th, the whoop and severe paroxysms of cough having disappeared, but with considerable wheezing in the chest and occasional cough. Commentary.—Cases of hooping-cough vary considerably as to the intensity of inflammatory and of spasmodic symptoms present, some- times one and sometimes the other being predominant. In the present case both were well marked. The bronchitis was intense, while con- densation of both lungs, from collapse, was present for a considerable time. The spasms, dyspnoea, constriction of the larynx, and attendant whoop, were also well marked. Having tried all kinds of remedies in this affection, without deriving much benefit from any of them, my notice was directed by the class to the strong statements of Dr. Gibb as to the value of nitric acid taken internally in this disease. According to him, it is as effectual as quinine in intermittent fever,* and it was therefore carefully given, and its use prolonged from the 19th to the 28th of June, but manifestly without the slightest benefit. Good nourishment, * See Dr. Gibb on Hooping Cough, p. 335. BRONCHITIS. 651 and latterly a little wine, enabled the patient ultimately to struggle through the disease, which was very severe. • I consider that hooping-cough is one of those disorders that runs through a certain course, and is very little affected by remedial measures. Our efforts should be directed to keeping the surface warm, preventing exposure to cold winds and alternations of temperature, and supporting the strength by good diet and a little wine. When the disorder becomes chronic, there can be no doubt that change of air often acts in at once removing the disease, much in the same way that it is frequently seen to relieve asthma. _ . Analogous to the nervous phenomena observed in hooping-cough is the laryngismus stridulus, or crowing inspiration of children, which, as pointed out by Dr. Ley, may often depend upon enlarged glands in the neck, and may originate in any cause irritating the recurrent nerve, di- rectly or indirectly, by diastaltic action, as ably pointed out by Dr. Marshall Hall. It is not an uncommon symptom, for instance, in aneurismal swellings affecting the throat and root of the neck. BKONCHITIS. Case CXXXV.*—Acute Bronchitis. History.—Martin Conolly, ast. 25, a robust laborer—admitted May 15th, 1657. On the 7th of May, after working some days standing in water, he had a rigor, with great heat of skin, followed by profuse perspiration, but no headache. He continued at his work till 10th May, when he was confined to bed, the pain having got worse. Cou"-h commenced the previous day, accompanied with a thick yellow sputum, and these symptoms, with dyspnoea, have gradually increased in severity up to his ad- mission. Symptoms on Admission.—Form of chest unusually rounded and well developed. Anteriorly, percussion is clear on both sides. On auscultation, inspiration is short- ened ; expiration prolonged, and accompanied by long sibilant and sonorous rales. Vocal resonance weak, but equal on both sides. Posteriorly there is clear resonance on percussion on both sides. On auscultation, the same sibilant and sonorous rales accompany expiration, and are occasionally but rarely heard with inspiration, which at the ri<*ht base is accompanied by moist rales. Cough and dyspnoea urgent. Re- spirations 36 per minute. Expectoration gelatinous and muco-purulent. Cardiac sounds somewhat masked, but normal. Pulse 122, strong, full, and regular. Skin hot, but otherwise normal. Tongue moist and clean. Appetite much impaired. Thirst great Bowels regular. Urine high colored, otherwise normal. V enesection to 14 oz was performed by Dr. Bennett without any immediate relief, and § ss of the following mixture ordered to be taken every four hours. R. Aqua; Acetatis Ammo- nia; = iss; Spirit. jEther. NUrici 3 ij ; Vm. Antimonial. 3 ij ; Aquam ad §■vj. In the evening, dyspnoea had much diminished. Respirations 24 per mmute. Pulse 108, still regular, full, and strong. Heat of skin less. Progress of the Case.—Next day improvement was found to contmue. Pulse 116, full, but softer than yesterday. Sibilations no longer audible with expiration. The moist sounds are fainter and less abundant than at last examination. May 18th. —Sibilant and cooing rales accompany both respiratory acts posteriorly. Anteriorly these sounds are less°intense, but are accompanied by fine crepitus. Under the left nipple, crepitus is mixed with a certain harshness, both on expiration and inspiration (friction'') Urine rendered turbid by the presence of urates. Pulse 116, of the same character as yesterday. May 19th (twelfth day of the disease). Patient was found bathed in profuse perspiration. The moist sounds are diminishing m amount. Crepi- * Reported by Mr. W. H. Davies, Clinical Clerk. 652 DISEASES OF THE RESPIRATORY SYSTEM. tation still audible under left nipple. Patient still complains of pain in that region, but there is no friction. Cough continues, but is less severe. Sputum still copious and muco-purulent. P\ilse 102, soft. Appetite improving. Skin moist. Urine throws down a copious sediment of urates. May 21st (fourteenth day).—Patient still per- spires profusely. Crepitation with fine sibilus still heard anteriorly, most distinctly under left nipple. Pain in left side continues, being most severe on deep inspiration. Sputum diminished in quantity, muco-purulent. Pulse 100, soft and full. On the 25th, moist rattle had nearly disappeared. On the 29th, sibilations were very faint, the cough was trifling, and sputum nearly gone. June 4th.—He was discharged quite well. Commentary.—This was a case of violent acute bronchitis of both lungs, in a strong vigorous man. On admission, so great was his dyspncea, that I bled him with a view of determining whether the re- medy would relieve that symptom. I satisfied myself that it had no im- mediate effect, and the disease subsequently ran its natural course, ter- minating in perfect recovery on the twenty-first day. Bronchitis, like laryngitis, consists of an exudation infiltrated into the various tissues forming the bronchi, or coagulated upon their mucous surface. It terminates in the transformation of this exudation—accord ingto laws previously explained, p. 166 et seq.—into matters which permit of being either absorbed into the blood or expectorated. At first the lesion causes increased dryness, narrowing, and rigidity, and subsequent- ly moisture, dilatation, and relaxation of the tubes. Owing to these changes, the vibrating sounds caused by the passage of air through the bronchi undergo variations, which indicate pretty clearly the dry or moist nature of the disease, or, as some term it, dry or moist catarrh. Acute bronchitis may differ in intensity, from an affection very tri- fling and scarcely regarded, to one which very nearly approaches in se- verity a decided attack of pneumonia. It may be epidemic, and con- stitute what is called influenza. It may follow or precede a similar lesion in the lining membrane of the nasal passages, that is, coryza. These affections are so common as to be generally treated by domestic medi- cines only, or, it may be, totally disregarded. But there can be no doubt that a disposition to attacks of this kind, though they may often occur for a long time with impunity, frequently leads to the incurable and distressing change of pulmonary texture known as emphysema, with its fearful accompaniment of spasmodic asthma and consecutive diseas.' of the heart. Bronchitis, therefore, is an affection which, if not check- ed early, should be carefully assisted through its natural progress. To check the progress of an incipient bronchitis or coryza, when slight, Dr. Christison recommends a full dose of morphia on the first, or at latest second night, on going to bed. In the morning the patient should breakfast in bed, and keep himself warm at home during the day. Should the disease progress, patience is perhaps the best remedy, as the disease will run its course. But if the bronchi become clogged, sudori- fics and expectorants, especially ipecacuanha, may be useful, and a sina- pism or blister will sometimes dissipate any lingering trace of the dis- ease. The chief caution to be given should be to get perfectly rid of the disorder before any exposure to cold air be allowed. It is the dis- regard of this point, and the getting " cold upon cold," which serves so much to keep up the affection, and at length induces the chronic form of the disease. BRONCHITIS. 653 Case CXXXVL*— Chronic Bronchitis—Acute Peritonitis—Collapse of the Luny. History.—MaryNichol, set. 21, a servant—admitted July 8th, 1851. She has suf- fered more or less from cough for the last two years. Occasionally it has been very troublesome, but not accompanied by much expectoration. Seven weeks ago experi- enced severe pain in the epigastrium, and since then the breathing has become short and hurried. Symptoms on Admission.—Anteriorly the lungs are everywhere resonant on per- cussion. On auscultation, the inspiratory murmur is harsh, and towards its termina- tion fine sibilant rales are heard. Posteriorly, the right side is more dull on percus- sion than the left. This is more marked towards the apex. At this point there is harsh inspiration and increased vocal resonance. There are also, over the whole right back, sibilant rales during inspiration. Cough, with trifling mucous expectora- tion ; respirations short and hurried; great tenderness over the epigastrium, increased on taking a deep inspiration; appetite tolerably good; no nausea or vomiting, and, with the exception of constipation, digestive system healthy; pulse 80, soft; heart sounds natural; catamenia regular ; urine voided with pain, and in small quan- tity, otherwise healthy. Progress of the Case.—The dry rales accompanying the inspiration continued for some days; but on the 21st they became moist, and coarse crepitation was audi- ble over the inferior third of right back. The cough became more loose also, and the expectoration increased. On the 24th, the moist rattles were converted into deep sonorous murmurs, and great variations were heard from day to day, evidently in con- sequence of the greater or less amount of fluid in the bronchi. The cough and ex- pectoration also varied greatly in intensity. Her principal complaint, however, was the epigastric pain, which, notwithstanding the application of leeches, warm fomenta- tions, opiates, and counter-irritants, continued to increase. On the 28th there was diffuse swelling of the abdomen, general tenderness of the surface, and all the symp- toms of peritonitis from intestinal perforation. Latterly there was dulness and ab- sence of respiration over the lower third of right lung. She died August 10th, 1851; but unfortunately no dissection could be procured. Commentary.—This girl labored under a chronic bronchitis of some standing, which presented, during the progress of the case, most of the physical signs characteristic of the disease. Her chief complaint, how- ever, was a fixed pain in the epigastric region, which proved in no way amenable to treatment, and which, as the event proved, was evidently connected with an ulcer either in the stomach or neighboring intestinal viscera, probably the former, considering the frequent occurrence of ulcers in that viscus among servant girls. But in the absence of the facts which a dissection only could have afforded, all speculation on such a point is evidently useless. The dulness on percussion at the apex of the right lung, the harsh inspiration and increased vocal resonance, point to the existence of some condition of the organ at that point, giving it increased density. They constitute the signs of incipient or ,of cretaceous tubercle. But percussion over the whole of right back was impaired; and towards the close of life, as weakness appeared, there was dulness and absence of respiration over the lower third of right lung. These physical signs indicate collapse of the organ in this situa- tion, or a condition which has been variously called by pathologists " condensation "—"infarction "—"hypostatic pneumonia "—" peri-pneu- monie des agonisans," etc. etc. In a series of observations on bronchitis, by Dr. W. T. Gairdner,f he points out, as one of the most common results of the disease, more or less collapse of the vesicular tissue, dependent on obstruction to the * Reported by Mr. C. D. Phillips, Clinical Clerk. f Papers in Monthly Journal for 1850. 654 DISEASES OF THE RESPIRATORY SYSTEM. passage of air during inspiration, by glutinous or inspissated mucus. This collapse is often confined to individual lobules, which are condensed, comparatively heavy, indurated to the feel, of dark color, and present the usual characters of the unexpanded portions of lung in the newlv- born infant (atelectasis). Doubtless, also, such collapsed lobules have often been mistaken for lobular pneumonia, or pulmonary apoplexy in children. Dr. Gairdner has further recorded facts, which render it highly probable that this collapse becomes more diffused in chronic cases of bronchitis, when a large bronchus is obstructed, as represented Fig. 449, and when, from the weak- ness of the individual, from abdominal disease, or want of resistance in the thoracic walls, the pa- tient is unable to clear the air-passages by a strong expiratory effort. Hence why this lesion is com- mon in fever, in bronchitis accompanying perito- nitis or ascites, and in young children. The case 449> recorded is evidently one where, from the physical signs and other symptoms, we can have little doubt that collapse in the right lung occurred to a considerable extent. Case CXXXVII.*— Chronic Bronchitis—Emphysema—Acute Laryngitis. History.—Edward Jackson, set. 22, a robust negro, cook to a vessel—admitted February 14, 1851. He says that three months ago, when at sea, he first began to suffer from cough, expectoration, and shortness of breath, which symptoms, notwith- standing various remedies given him by his captain, have continued to increase up to the present time. Symptoms on Admission.—Anteriorly the thorax is unusually arched from above downwards. On percussion, there is everywhere loud resonance, especially in front. On auscultation, the expiration is much prolonged, and accompanied by sibilant and sonorous rales, louder and more general on the right side. There is frequent and pro- longed cough, accompanied by copious frothy mucous expectoration, great dyspnoea on making an exertion, and occasionally coming on in paroxysms without any obvious cause. Cardiac sounds normal. Pulse 80, strong. Frequently vomits after a severe fit of coughing; but the digestive and other systems are otherwise healthy. Progress of the Case.—In addition to the dry rales heard when he was first ex- amined, it was soon ascertained that copious coarse moist rales appeared posteriorly and inferiorly, especially on the right, but also on the left side. These rales were oc- casionally absent, but continued tolerably constant. The dry rales also underwent from time to time several variations in tone, intensity, and situation. During February, May, and June, he was tortured by severe and prolonged attacks of dyspnoea, during which he gasped for breath, and appeared on the point of suffocation. The attack generally terminated by violent cough, expectoration, and vomiting, after which he always felt relieved. These attacks came on every second or third night, and were sometimes occasioned by an unusually full meal. In May there was noticed, in addition to the other physical signs, a coarse moist tracheal rattle, so loud as to mask the pulmonary sounds. On one occasion, during this month, the attack of dyspncea lasted four hours, producing partial asphyxia, delirium, and stupor. On the 24th of May, he was attacked with sore throat, and difficulty in deglutition, followed on the 39th by laryn- gitis and partial aphonia, which greatly aggravated the asthmatic attacks. During all this time, expectorants, antispasmodics, anodynes, counter-irritants, with occasional * Reported by Mr. W. M. Calder, Clinical Clerk. Fig. 449. Plug of mucus or coagulated blood, so placed that, while it admits of partial expiration, it prevents inspiration and causes collapse of the pulmonary tissue, to which the smaller bronchi are distributed.—(Gairdner.) BRONCHITIS. G55 emetics, and cupping, were employed, with temporary but no permanent benefit. In April and May the smoking of stramonium evidently afforded him considerable ease. He also experienced marked relief from a draught containing 3 iss each of Tr. Lobe- lia; and of Ether. Towards the end of June, a sponge, saturated with a strong solu- tion of nitrate of silver, was passed into the larynx several times, with marked bene- fit- indeed, so much so, that, on the 11th of July, his condition was greatly im- proved the attacks of dyspncea ceased, and the cough, expectoration, and other symptoms were much abated. On the 16th, he was dismissed at his own request, to resume his occupation as cook on board ship. The sore throat and laryngitis had then disappeared, but the chest was still unusually resonant on percussion ; there was loud tracheal breathing, prolonged expiration, and occasional sibilant rale. Respira- tion, however, was comparatively easy, and he considered himself, as he certainly was, greatly relieved. Commentary.—This man presented all the physical signs and symp- toms indicative of extensive emphysema dependent on chronic bronchitis, accompanied with the most severe asthmatic attacks. These attacks were of a spasmodic character, referable to irritation of the inci- dent filaments of the pneumo-gastric nerve, and to reflex action by means of the excident ones, whereby the bronchial tubes were contract- ed, the glottis closed, and the muscles of inspiration rendered incapable of dilating the chest. Violent cough and vomiting were always induced towards the close of the attack, followed by relief. The dyspnoea dur- ing the course of the disease was alleviated by antispasmodics, and the laryngitis by topical applications, of which I have previously spoken. I consider, however, that his recovery was mainly due to the advance of summer and a change of temperature—circumstances which should never be overlooked in estimating the effects of treatment in such cases. Of all the causes which excite asthmatic paroxysms in individuals laboring under emphysema, the effect of certain seasons and changes of temperature is the most unequivocal, and yet the most mysterious. Thus some persons who are martyrs to the disease in winter are perfect- ly well in summer, and vice versa. Some are immediately affected by the foggy air of London, and are well in the country; others are at- tacked when the wind blows from a particular quarter, especially the east. However difficult it may be to explain such idiosyncrasies, there can be no doubt that a knowledge of these circumstances will enable those who can change their residence, to alleviate their sufferings in no small degree. Emphysema is characterised anatomically by a permanent enlarge- ment of the air-vesicles of the lung. These may frequently be seen through the pleura, with an ordinary lens, like groups of minute pearls. Two or more of them may break into each other, and produce others of larger dimensions, say the size of a millet seed, and this process may go on, until, by the breaking down of the intervening partitions, every size of emphysematous cavity may be formed, up to that of a large orange. The walls of such cavities remain permanently open, having lost their elasticity. The tissues which form them also are evidently atrophied, and their paleness proves that the capillaries have been so compressed as to be either obliterated or impervious to the passage of blood. In order to account for emphysema, numerous theories have been advanced, of which I shall allude to only the first and last. Laennec 656 DISEASES OF THE RESPIRATORY SYSTEM. supposed that the fine bronchial tubes became rigid and more or less im- pervious from swelling of their lining membranes or impaction of mucus. He conceived that inspiration was a more powerful action than expira- tion, so that while air could be drawn through the obstructions, it could not be breathed out. In consequence, it accumulated in the ultimate pulmonary vesicles, became expanded by heat, and so acted mechanical- ly as a dilator, distending them from within, and causing them to en- large more and more according to the duration of the disease, and ex- tent of the respiratory efforts. Dr. Gairdner, however, has pointed out that expiration is a much more powerful act than inspiration, and that there is never any difficulty in causing expulsion of air. It is the in- spiration which is laborious in all bronchitic cases, and, as has been previously stated, when the tubes are obstructed, so far are the air-cells beyond them from being dilated that they are in truth collapsed. Em- physema, then, does not occur in the vesicles connected with obstructed tubes/but in those healthy ones which are adjacent. When the lungs are in a normal state, the column of air presses equally on the tubes and vesicles, but when one portion connected with any obstruction is col- lapsed or otherwise diminished in bulk, then the neighboring portion is over-expanded, so as to occupy the space previously filled by the former. Hence why emphysema occurs not only as a result of bronchitis, but of chronic phthisis, or any other disease which causes contraction and hypertrophy of the pulmonary fibrous tissue. Dr. Jenner also says,* " The atmospheric air moved by the inspiratory effort can exert com- paratively little pressure on the inner surface of the air-cells situated at the extreme margin of the base, the root of the lower lobe (i. e., that part immediately next the spine and below the primary bronchus), or at the part of the apex situated in the furrow posterior to the trachea on the-right side. While violent expiration, being chiefly performed or greatly aided by the abdominal muscles forcing upwards the liver, etc., drives the air (in consequence of the highly arched form of the dia- phragm in violent expiration) from the central part of the lung, not only through the bronchi towards the larynx, but also towards the circumfer- ence of the lungs, i. e., towards those parts which are the least com- pressed during expiration." This view is confirmed by allthat we know of ,the usual seat of emphysema^ and by the effects of expiration as made visible under particular circumstances. In the case of M. Groux, in whom the sternum was deficient, it could be demonstrated that it was only by a forced expiration that the lungs so expanded, as to protrude through the aperture.f The treatment of chronic bronchitis must be directed to facilitate expectoration by means of various expectorants, and to allay the irrita- bility of the bronchial passages by means of anodynes. I have already alluded to the circumstance, that chronic pharyngitis, tonsillitis, elonga- tion of the uvula, and follicular disease of the epiglottis, keep up a cough, often mistaken for chronic bronchitis; and it is in these disorders that demulcents, lozenges of various kinds, astringent and stimulating gargles. etc., are found temporarily beneficial. In such cases the employment of * Medico-Chir. Trans, of London, vol. xl. f Edin. Med. Journal, vol. iii., p. 853. 1858. BRONCHITIS. 657 the sponge, saturated in a solution of nitrate of silver, is, as we have seen in Case CXXXVII., of the greatest advantage. Perhaps there is no disease in which blisters and counter irritations are more useful than in bronchitis. When chronic bronchitis is associated with emphysema, and accom- panied by spasmodic attacks of dyspncea, the various kinds of antispas- modics are most serviceable. Sulphuric and chloric ether often act like magic; and the smoking of stramonium, with or without opium, and other remedies of this class, though they seldom cure, produce great relief. The idiosyncrasy of the asthma should also be studied, and a change of temperature or locality advised, according to the peculiarities of the case. In very severe and chronic cases this may be regarded as the only curative procedure. Case CXXXVIII*—Chronic Bronchitis—Emphysema—Injection of the Bronchi with a solution of the Nitrate of Silver. History.—Eliza Dawson, aet. 24, a servant—admitted 27th May 1857.—About fourteen months ago, after exposure to damp and cold, she was seized with a severe pain in the chest accompanied by cough. The pain in the chest disappeared in a few days, but the cough persisted, though it was not very troublesome, till twelve months ago, when again it became very severe, the house in which she was living being damp. The pain in the chest at the same time returned. In the middle of last January the pain and cough increased in severity, and were accompanied by consider- able dyspncea. She derived no benefit from treatment-- and was at length compelled to apply for admission, because her weakness was such as to prevent her continuing at work. Symptoms.—On percussion over the chest, resonance is very loud both anteriorly and posteriorly. On auscultation, expiration is everywhere prolonged. Sibilant and snoring sounds accompany inspiration and expiration on both sides, anteriorly and posteriorly. Vocal resonance everywhere diminished. Cough and dyspncea paroxys- mal ; the respiration being labored even in the intervals. Expectoration in moderate quantity, consisting of frothy fluid floating over tough gelatinous mucus. Apex of heart cannot be felt. Cardiac sounds normal, but masked by the pulmonary sounds. Pulse 74, of moderate strength. Tongue clean, but somewhat dry. Appetite impaired. Feels pain in the epigastrium after taking food. Bowels generally constipated, requiring the occasional use of aperients. Other functions normal. R Spirit. ^Ether. Nitric. 3iij ; Spirit. Ammon. Aromatic. 3 iv; Aquam ad § vi. A table-spoonful to be taken thrice a-day. The chest to be dry-cupped anteriorly and posteriorly. Progress of the Case.—She has experienced great relief from the treatment, and on 1st June the snoring sounds are reported to have disappeared. On that day, how- ever, the dyspncea again became distressing, and on 3d June, the sibilant and sonor- ous rales had returned. Was ordered Spirit. ^Ether. Sulphuric. 3 ij.; Sol. Mur. Morph. 3 iss ; Decoct. Senega; ad §vi. A table-spoonful to be taken thrice a-day. A blister (3 by 4) to be applied over the chest. This was followed by great relief; sibilus continued audible, but the sputum diminished in quantity, becoming altogether mucous. On the 13th, cough and dyspncea again became severe, with pain in the chest. A blister (3 by 4) was again applied with benefit. 21th June.—The dyspnoea has re- turned during the last few days, the paroxysms occurring chiefly during the night. During the fit she sits up in bed; the whole chest heaves; the head is thrown back during inspiration ; the face is unusually pale and moist with perspiration; lips pallid; articulation slow and measured; respiration accelerated with prolongation of expira- tion. A drachm of sulphuric ether, and half a drachm of Sol. Mur. Morph. in a draught, gave immediate relief. The fits now became less frequent, diminishing at the same time in severity and duration. On 13th July, after the previous application for a few days of the sponge to the throat, Dr. Bennett injected, by means of a catheter introduced into the trachea, 3 ij of a solution containing half a drachm of nitrate of silver to | j of water. The operation was repeated next day. There was no return of dyspnoea till 15th July, when she had two paroxysms, both followed * Reported by Mr. Stephen Scott, Clinical Clerk. 42 658 DISEASES OF THE RESPIRATORY SYSlEM. by vomiting. She had a third paroxysm next morning at 4 o'clock, nhich left her very weak; respiration at 2 p.m. being still considerably embarrassed. On 17th July, 3 ij of the solution of nitrate of silver were again injected into the trachea. No difficulty is experienced in passing the tube, nor is any inconvenience felt by the patient. The presence of the catheter in the trachea was demonstrated by the propul- sion of 2 oi 3 drops from the external orifice to a distance of 3 feet during a forcible expiration. After the operation, she passed a much better night; the cough and ex- pectoration being very much less, and the respiration perfectly easy. On 22d July the operation was repeated; she vomited in an hour and a half after it, but remained com- paratively free from cbugh and dyspnoea till 30th July, when a re-accession occurred, On 1st August, 3 ij of the solution were again injected, and on 4th August she left the Infirmary to obtain change of air. Commentary.—This also was a case of chronic bronchitis, with em- physema and severe paroxysms of asthma, in which various remedies were tried with the effect of temporarily alleviating the dyspncea. Dur- ing her residence in the house, much of the bronchitis gradually disap- peared, but the emphysema and asthma continued and underwent little change. It appeared to me a favorable opportunity for trying the new practice introduced by Dr. Horace Green of New York, of bronchial in- jections with a solution of nitrate of silver. We were singularly favored in this case by the high position of the epiglottis, and the com- parative insensibility of the larynx. The sponge saturated with the nitrate of silver solution, apparently caused no irritation whatever, and on passing the catheter through the rima glottidis little uneasiness was manifested. Two drachms of a solution ( 3 ss of the salt to ?j j of water) were injected into the trachea several times, producing only a feeling of warmth in the chest, but, as she frequently declared, greatly diminish- ing the cough and expectoration from one to two days afterwards. This woman, with the catheter deep in the trachea, closed ber mouth round the tube, respired through it, and could blow so as to render the ex- pelled air quite sensible to the finger. No one could doubt that the tube was in the trachea, and that the solution had passed into the lungs. After her dismissal, I continued to see her, and subsequently increased both the, strength and quantity of the injection. Latterly I have thrown in § ss of the strength of £ij of the salt to ^ j of water. She emigrated to Australia, May 1858. On Injections into the Bronchi in Pulmonary Diseases. In a publication which I received from Dr. Horace Green of New i ork in 1856, there is a table of 106 cases of pulmonary disease, which were treated by injections into the bronchi of a solution of nitrate of silver. A flexible catheter was introduced through the larynx, into the right or left division of the trachea, and, by means of a glass syringe, the injection thrown into the lung. This bold proceeding was described as producing great benefit in cases of pulmonary tuberculosis, bronchitis, and asthma. Whilst tuberculosis is at first a constitutional disease, it.« localization in any part reacts more or less on the general health ; and the opinion I have long entertained, that any means which could enable the physician to act directly on the tissue of the lung or inflamed bronchi, would assist his efforts at cure—at once led me to take a favor- able view of this new mode of treatment. The nitrate of silver ought to act as beneficially on the mucous membrane of the trachea and bronchi BRONCHITIS. 659 as on that of any other hollow viscus, and we have seen previously that the remedy may be applied to the tracheal mucous membrane by means of an artificial opening (see Case CXXXIIL), not only without injury but with decided benefit. The difficulty was obviously to get it there through the rima glottidis. I therefore wrote to Dr. Green, requesting him to send me the instruments he employed. In a letter which I re- ceived from him in reply, dated New York, January 30, 1857, he says:— " I would, with much pleasure, send you the instruments I employ, but they are simple, and may be obtained at any surgical instrument maker's shop. They consist of an ordinary flexible or gum catheter, and a small silver or a glass syringe. The catheter is Hutching's gum- elastic catheter (Nos. 11 or 12), which is 12A- inches in length ; and as the distance from the incisor teeth to the tracheal bifurcation is, ordi- narily, in the adult, about eight inches, if this instrument is introduced so as to leave only two inches of the catheter projecting from the mouth, its lower extremity must of course (if it enter the trachea) reach into one or the other of its divisions. I first prepare my patients by making applications with the sponge-probang, for a period of one or two weeks, to the opening of the glottis and the larynx, until the sensibility of the parts is greatly diminished. Then, having the tube slightly bent, I dip the instrument in cold water (which serves to stiffen it for the moment, and obviates the necessity of using a wire), and with the patient's head thrown well back, and the tongue depressed, I place the bent extremity of the instrument on the laryngeal face of the epiglottis, and gliding it quickly through the rima glottidis, carry it down to or below the bifur- cation, as the case may require. It is necessary that the patient continue to respire, and the instrument is most readily passed during the act of inspiration. The tube being introduced, the point of the syringe is in- serted into its opening, and the solution injected. This latter part of the operation must be done as quickly as possible, or a spasm of the glottis is likely to occur. Indeed, if the natural sensibility of the aperture of the glottis is not well subdued by previous applications of the nitrate of silver solution, or if the tube in its introduction touches roughly the border or lips of the glottis, a spasm of the glottis is certain to follow, which will arrest the further progress of the operation. The epiglottis, which is nearly insensible (and this you may prove on any person, by thrusting two fingers over the base of the tongue, and touching, or even scratching with the nail, that cartilage), should be our guide in perform- ing the operation. The strength of the solution for injecting is from 10 to 25 grains to the ounce of water. Commencing with 10 or U5 grains to the ounce, its strength is subsequently increased, and the amount I now employ is from \ to \\ drachms of this solution. " In oases of bronchitis, asthma, and in phthisis, even the employ- ment of the tube once or twice a week diminishes the cough and expec- torations with great certainty, especially in the two former diseases; and many cases have recovered under the local treatment after other means have failed. The applications of the sponge-probang are continued in the intervals of the employment of the tube." My period of attendance on the clinical wards having expired in January, it was not until May 1857 that I had an opportunity of making a series of observations on this subject. I was then fortunately assisted 660 DISEASES OF THE RESPIRATORY SYSTEM. by Professor Barker of New York, who showed me the kind of cathetei he had seen Dr. Green employ, and demonstrated the manner in which the operation was performed. Without entering into minute particulars, I have only to say that I have confirmed the statements made by Dr. Horace Green. I have now introduced the catheter publicly in the clinical wards of the Royal Infirmary, in several patients affected with phthisis in various stages, in laryngitis, and in chronic bronchitis, with severe paroxysms of asthma. In other cases in which I attempted to pass the tube it was found to be impossible; in some because the epiglottis could not be fairly exposed, and in others on account of the irritability of the fauces, and too ready excitation of cough from pressure of the spatula. I have been surprised at the circumstance of the injections not being followed by the slightest irritation whatever, but rather by a pleasant feeling of warmth in the chest (some have experienced a sensa- tion of coolness), followed by ease to the cough, and a check for a time to all expectoration. In making these injections, I have observed very great differences in the* form of the epiglottis, as well as in the irritability of the fauces and root of the tongue in different individuals. In some persons the epiglottis is easily exposed, and on depression of the tongue may be seen standing erect, quite insensible as stated by Dr. Green, so as easily to permit the passage of the catheter. In other cases, the top of the epiglottis can only be reached with the greatest difficulty, and in several is not to be seen at all. In such cases I have not as yet attempted to pass the catheter. Again, while some individuals can bear without difficulty forcible depres- sion of the tongue, and considerable freedom in touching the fauces and rima glottidis, others are thrown easily into violent spasms, or exhibit great irritation in the parts, from the mere pressure of the spatula. This appears to me to be more constitutional than dependent on local disease; some persons being more irritable or easily excited than others, and I have observed the same difference in individuals who are in all respects perfectly well. On one occasion I put the sponge through the rima, and allowed it to remain some seconds, completely obstructing respiration, but without causing cough or any other inconvenience. In the case of Dawson (Case CXXXVIIL), very trifling irritation was occasioned by the pressure of the catheter. Whenever great irritability exists, the operation ought not to be performed. One phthisical gentleman who, with a desire to have the operation com- pleted, violently restrained all efforts to cough when I was in the act of injecting the solution, experienced great pain in the chest for several days. PLEURITIS. Case CXXXIX.*—Acute Pleurisy—Recovery. History.—Mary Harvey, set. 21, a robust servant girl, was admitted into the clinical ward, July 23, 1851. She enjoyed good health until seven days ago, when, after unusual exposure to cold and wet, whilst washing clothes, she was seized with difficulty of breathing, and a sharp cutting pain in the right side. She shortly afterwards experienced headache, general soreness, and the usual symptoms of fever, * Reported by Mr. C. D. F. Phillips, Clinical Clerk. PLEURITIS. 661 but does not remember having had rigors. The dyspnoea and local pain have increased in intensity, although the febrile symptoms on admission had somewhat abated. Symptoms on Admission.—On percussing the right lung anteriorly, there is com- plete dulness over its lower half, and, posteriorly, the dulness extends over the two lower thirds of the lung. On the left side, the lung is everywhere resonant on per- cussion. On listening over the dull portion of right side, there is complete absence of respiration, with loud pealing vocal resonance. In the centre of lung posteriorly aegophony. No friction or crepitating murmur can be distinguished. On the left side, respiration is puerile. Slight cough, but no expectoration; dyspncea, but not urgent; sharp cutting pain in right side, increased on taking a deep inspiration. Considerable headache and general soreness; the skin of natural temperature, but dry. Pulse 100, of natural strength; tongue furred ; face flushed; no appetite; great thirst; func- tions of the body otherwise well performed. Progress of the Case.—On the following day the dyspncea and pain had diminished. On the morning of the 25th there was considerable sweating, and next day a copious sediment of phosphates and lithates appeared in the urine, and it was observed that the febrile symptoms had disappeared. The pulse was 84, soft. On auscultation, a friction murmur could be heard at the upper margin of the dulness on the right side. On the 3d of August the pulse was 72, and weak. The pain still con- tinued, and the physical signs were the same. On the 6th, the extent of the dulness, the aegophony, and the vocal resonance, began to diminish, and the friction murmur to increase. On the 9th no friction could be heard, and the respiratory murmurs were audible in the primary dull portion of lung. On the 27th, with the exception of slight dulness, she was quite well and was dismissed by her own desire. On admis- sion, twelve leeches were applied to the affected side, followed by warm fomentations. Two purgative pills were administered, and a third of a grain of tartrate of antimony, with 3 ss of solution of muriate of morphia, ordered to be taken every four hours. Subsequently a succession of blisters was applied to the right side. On the 3d of August she was ordered a pill of calomel and opium three times a day. All the sis prescribed were not taken, and no physiological action of the drug resulted. Commentary.—This was a case of uncomplicated acute pleuritis, with all the characteristic symptoms and signs, as described by systematic authors. The fever terminated by crisis through the skin and kidneys on the tenth day. The physical signs commenced to disappear on the seventeenth day, but had not wholly vanished until the thirty-fifth day. On admission, there must have been a considerable amount of ex- udation, with serum subsequently separated from it compressing the lung, so as to destroy the respiratory murmurs inferiorly. At the upper margin of the dulness, however, aegophony was heard, a sign as often absent as present in pleurisy, and certainly not deserving the importance which Laennec attached to it. The diminished action in the compressed lung was evidently counterbalanced by increased action in other portions of the pulmonary organs, as determined by the puerile respiration on the opposite side. Lastly, it was very instructive to observe how, as the fluid became absorbed, and the pleural surfaces were thereby allowed to come into contact, friction sounds were developed, and then ultimately disappeared, when union between these surfaces may be supposed to have taken place. The treatment slightly diminished the pain in the side, but in other respects evidently had no effect whatever on the progress of the disease. Case CXL.*—Acute Pleurisy without Functional Symptoms—Rapid Recovery. History.—Peter M'Guire, aged 21, laborer—admitted September 12th, 1856. States that in June last he was seized with pain in right side, hot 6kin, and slight * Reported by Mr. A. Turnbull, Clinical Clerk. 662 DISEASES OF THE RESPIRATORY SYSTEM. fever, for which he was bled, blistered, and confined to bed for a fortnight. He per- fectly recovered, but for the last five weeks he had been unable to carry on his usual employment, in consequence of pains in his right shoulder, arm, and side. On Tues- day last (the 9th), these pains were unusually severe, accompanied, as he says, by dyspnoea, thirst, and heat of skin. On the following day (10th), although not confined to bed, he could not go to his work; and finding no improvement take place, he came to the hospital. Symptoms on Aomission.—Percussion note over whole of the left side of thorax is resonant. Respiration is somewhat puerile. On the right side the lung is every- where resonant on percussion, except posteriorly, where there is slight dulness below the level of the angle of the scapula, and laterally, below the level of the sixth rib. On auscultation over the dull portion, respiration is faint, but there is no friction or crepi- tation to be heard. At the apex the respiration is harsh, and the vocal resonance is louder than on the other side. At the base near the spine there is an approach to aegophony. Cough slight, attended by little pain. Expectoration scanty and frothy. No pain in right side, nor uneasiness in taking a deep inspiration. Circulatory system normal, with the exception of the pulse, which is 96, full. Bowels constipated. Ap- petite bad. Considerable thirst. Urine clear; does not coagulate on being heated, nor on the addition of nitric acid. Chlorides abundant. R Pulv. Ipecac. Co. gr. xii to be taken at bed-time. Progress of the Case.—September 14th.—Has not perspired much during the night. Complains of. slight palpitation, but has no pain of any kind. Heart's sounds normal. On percussion over the right side of chest, the line of dulness, which in the recumbent position is at the fifth intercostal space, rises as high as the third when he sits up in bed. 15th.—Line of dulness now extends up to the second rib anteriorly, and is the same in all positions. Vocal resonance above the right nip- ple is loud, but breathing faint. At the apex, the expiration harsh and very much prolonged. Was ordered one-twelfth of a grain of antimony every four hours. Had a blister applied last night, which has risen well. Sept. 11th.—No pain in the side even on a deep inspiration. Has no fever; appetite good; expresses himself as much better. Pulse 100, small and weak. Dulness has become universal over the right side posteriorly, and anteriorly ascends to the second rib, above which a cracked- pot sound is audible. There is now no difference on percussion, when in the upright and when in the recumbent position. Respiratory murmurs posteriorly are feeble and distant, not healthy; aegophony well marked. On the left side posteriorly, expiration is puerile. Anteriorly on right side, respiration exaggerated superiorly, feeble in- feriorly, and vocal resonance increased. No friction murmur anywhere audible. Sept. 18th.—Dulness has extended higher. Cracked-pot sound more limited, but increased in intensity under the clavicle. Posteriorly an occasional friction sound was detected; ordered to have this part painted with iodine. Sept. 19th.—Dulness now clearly limited by a fine, the convexity of which is downwards, its greatest distance being from the clavicle one and a quarter inch, and its smallest distance one quarter of an inch. Sept. 1st.—Cracked-pot sound—now limited to a spot below the sterno- clavicular articulation—is not so audible. Complains of dyspncea when walking. Sept. 22d.—Cracked-pot sound replaced by a somewhat metallic sound. Patient feels so much better, that he is anxious to leave the hospital to resume his labors. 23d—Very little expansion of right side of chest even on deep inspiration. A warm poultice to be apphed over the whole right side of chest. 26th.—Patient complains that after walking quickly he experienced dyspncea. Hot spongio-piline to be ap- plied to foment the whole side. Patient takes three ounces of wine daily. 21th.— The convex line of dulness anteriorly, which has for seven days been stationary at the line mentioned on the 19th, has now become lower, and not so clearly defined. No cough nor expectoration. Pulse 80 per minute, rather feeble. Appetite pretty good. Fomentations and wine continued. October 2d.—Resonance in front, and internal to the nipple, extends as far down as sixth intercostal space. Dulness to the right of the nipple still remains. The resonant portion at the anterior and upper part of right side may be bounded by a line drawn from the upper part of the axillary region to the nipple. Pulse gradually gaining strength. 4th.—The an- terior portion of right side lias almost entirely regained its normal resonance. Lateral region of same side is also more clear on percussion. Anteriorly and laterally over fourth and fifth ribs, and posteriorly to a lesser degree, there is heard friction de retour. The palpitation has again returned, and on auscultation, a very soft murmur is heard with the first sound. 13th.—Percussion perfect over the whole of anterior PLEURITIS. 663 surface of right side of thorax ; still a little dulness posteriorly. Friction di retour is only slightly marked during ordinary respiration. 18th.—Both sides of chest expand equally on deep inspiration. Anteriorly over both sides of chest, resonance equal. Laterally, external to nipple of right side, there is marked sense of resistance and slight diminution of tone on percussion when compared with opposite side. Poste- riorly over whole of right side, percussion duller than over left, but still resonance is greatly increased to what previously existed. On auscultation posteriorly, respiratory murmurs equal on both sides; no friction anywhere but on right side; vocal reso- nance increased, especially laterally below the axilla. His general health has long been quite good, and he insisted on going out. Dismissed. Commentary.—On the admission of this man, it was supposed, and I still think correctly, that the comparative dulness which existed on percussion over the right back depended on the pleurisy he had had in the previous June, and that the wandering pains and slight fever were owing to rheumatism. Two days afterwards, fresh exudation was evi- dently poured into the right pleural cavity, and it is a remarkable fact that it continued to increase until the whole of that cavity was occupied, and this without fever, pain in the side, or any of those symptoms which are thought the usual indications of acute pleurisy. In this state the exudation remained stationary for seven days, then began to be absorbed, and gradually disappeared. In short, we had the most distinct evidence from physical signs of the commencement, onward progress, and decline of an acute pleurisy, without any functional symptoms whatever, the man all the time maintaining he was in perfect health, and being with great difficulty retained in the house for the sake of observation. In this respect, the case proves that an acute pleurisy, like an acute pericarditis (Case C), may be altogether latent, and at no period of its progress give rise to those symptoms with which systematic writers have made us so familiar. For another remarkable example of this fact, see Case CXXVII. It is unnecessary to comment in this place on the importance of such cases in reference to treatment, and to former view3 as to the good effects of blood-letting and antiphlogistic remedies. In the case of Stanbroke (Case XC VII.), we saw that a pericarditis required no such remedies to enable it to pass through its natural progress, and we have here another illustration of the same fact in reference to pleuritis. Local pain appears to be an accidental occurrence, and in no way essential to a true inflammation. Case CXLL*—Chronic Pleurisy on both sides—Bronchitis. History.—John O'Neill, set. 40, a writer—admitted into the clinical ward November 28th, 1850. Three weeks before admission, he was suddenly seized with a severe pain in his left side, which impeded breathing. Three days afterwards feeling better, he returned to his employment, but in the evening he experienced distinct rigors, and the pain returned. Strong febrile symptoms followed, with cough and expectoration. He has been under medical treatment since then, and now, on admis- sion, is considerably better. Symptoms on Admission.—On percussion, there is complete dulness over the whole of left side, anteriorly and posteriorly, with the exception of the infraclavicular region, where the dulness is incomplete. Over the whole of right side there is unusual resonance. The expansion of the chest is greatly diminished on the left side with absence of vocal fremitus. On auscultation, the respiratory murmurs are inaudible over left side, except at the apex, where there is prolonged expiration accompanied with sibilant rale. On the right side anteriorly, loud sibilant rales, both with inspira- tion and expiration. Posteriorly the respiratory murmurs are puerile. Increased vocal resonance, amounting to bronchophony, heard over whole of left side, assuming * Reported by Messrs. Cunningham and Calder, Clinical Cierks. 664 DISEASES OF THE RESPIRATORY SYSTEM. an segophonic character over scapular region. On right side vocal resonaace normal. Frequent and severe cough, followed by copious expectoration of frothy mucus. No pain in chest on taking a deep inspiration, but occasional " stitches " in left side. No dyspnoea. The apex of heart beats in the epigastrium, immediately below ensiform cartilage, and its sounds (which are healthy in character) are heard most distinctly on right side of sternum inferiorly. Pulse 68, small. Urine turbid, with deposit of lithates. Appetite good. Other symptoms normal. Progress of the Case.—On the 9th of December a friction sound was heard below the left clavicle, and the resonance on percussion was more diffused. On the 26th, loud friction sounds had extended from above on the left side down to an inch below the nipple, and dulness on percussion was confined to the two lower thirds of the lung. The bronchitis, also, was diminished, and on the 11th of January the cough and ex- pectoration had ceased, and the bronchitic rales had disappeared. On the 23c? of February a careful examination showed that there was complete dulness over left lung, from the nipple downwards, and that on auscultation there were loud double-friction sounds with absence of respiration. He now complained of dull pain on the right side of chest inferiorly, and on the following day there was heard in that situation a double- friction sound, which, however, disappeared on the 5th of March. It returned every now and then, accompanied by " stitches " more or less severe. On the 26? of April there was dulness over both sides of chest, anteriorly from the nipple downwards, to- gether with double-friction sounds on both sides. The expansion of both sides of chest is now equal—that on the left side having greatly increased, and the respiration being audible over its two superior thirds. During the whole of April the physical signs underwent no change, and he suffered considerably from dyspnoea. In May the dul- ness was more circumscribed on the left, and more extended on the right side. The dyspnoea, however, was diminished, and his general health so improved that he was enabled to take walks in the green. During the months of June and July he continued to improve, but complained of occasional pain in the chest, and cough, with slight ex- pectoration, originating apparently from imprudent exposure to cold. The respiration, however, insensibly extended itself inferiorly on the left side, and towards the end of July the dulness was greatly diminished on the right side also. At this time he was so well that he was dismissed, August 4. The treatment consisted at first of expectorants and anodynes to mitigate the bronchitis, together with a course of the iodide of potassium, and frequent blisters applied to the pleuritic side. In February, pills of calomel and opium were ordered, which caused slight salivation for a period of ten days. On the appearance of pleurisy on the right side, it was combated by frequent applications of leeches, followed by counter-irritation. The latter remedy was continued from time to time during his subsequent residence in the house, together with occasional expectorants, anodynes, anti-spasmodics, and purgatives, according as his symptoms required them. Commentary.—In this case the disease ran a more chronic course, beginning on the left side, and subsequently attacking the right. As the one declined, the other increased, and in both the physical signs deter- mined with great exactitude the extent of the fluid exudation, its subse- quent absorption, the rubbing of the diseased surfaces against each other, and, lastly, their subsequent adhesion. These changes occupied a period of upwards of eight months. Seeing the slow progress of the case, and the indisposition of the exudation exhibited to be absorbed, mercury was tried, and salivation maintained for ten days. At this time, such was the state of discomfort it produced, so thoroughly did it destroy the appetite and thereby diminish the vital powers, that it was discontinued. So far from causing absorption, the action of the drug not only failed to do so, but pleurisy on the opposite side actually developed itself while the system was under its influence. Surely facts of this kind ought to disabuse medical men of the notion, still very prevalent, of the power of this drug in causing absorption of an exudation. (See Pericarditis.) Pathology, Diagnosis, and Treatment of Pleuritis. The physical signs of pleurisy can scarcely be understood without an accurate acquaintance with the appearances which the exudation assumes PLEURITIS. 665 on the pleural surface. This is essentially the same as has been previ- ously described in the case of Pericarditis, pp. 174 and 175. In very acute cases of pleuritis, which have proved rapidly fatal, I have repeatedly observed the following appearances:—On elevating the sternum, care having been taken not to disturb the body for some hours, the pleural cavity on the side affected has been found full of an appar- ently clear fluid of a yellowish or greenish tint. On removing this by means of a small shallow cup, the first portions seem perfectly clear and transparent. On continuing to empty out the fluid, it has been ob- served that the deeper we descend the more turbid it becomes, until at length nothing but a semifluid mass is removed. It will frequently be found that large portions of this mass, although tolerably consistent, are semi-transparent, resembling a light-colored calf's-foot jelly, whilst other portions present the usual opaque appearance. Sometimes, when the body has been undisturbed for twenty-four hours, the whole exudation is separated into two distinct portions,—the upper, fluid and perfectly transparent, whilst the lower is composed of a pultaceous mass, re- sembling a bread-and-water or oatmeal poultice. In all such cases, the fibrinous portions, from their superior specific gravity, have sunk to the bottom, whilst the supernatant serum remains clear. The semi- transparent lymph is the portion most recently exuded, in which very few of the plastic corpuscles formerly described, p. 165 have been developed. When the progress of the exudation is less rapid, the coagulated fibrin or lymph assumes a more consistent appearance, and forms, over the part inflamed, flocculi of different sizes, or a distinct lining, varying in thickness from half a line to an inch. This is always villous, but sometimes it presents a honey-combed appearance, or hangs in the^serum in loose flakes of a dendritic character. A serous membrane, when in- flamed, resembles a mucous surface, and, in point of fact, performs the functions of one for a time, and is very active in absorbing the serum. Occasionally also it assumes a lamellar arrangement, attributable prob- ably to repeated exudations of blood-plasma at different times. This may be frequently observed on the pleura, and layer after layer may be readily dissected off. Sometimes there is more or less blood extravasated with exudation, causing it to assume various tints of red, mahogany, purple, etc., according to the amount thrown out, and the period which has elapsed before examination. When the inflammation has been less acute, or is of longer standing, we find, after death, that the coagulated blood-plasma or lymph has become more consistent. It assumes a more distinctly fibrous appear- ance, often extending between opposed serous surfaces in the form of bands, which have considerable tenacity and strength. These bands have a great disposition to contract, and ultimately become shorter and shorter, and assist in forming a dense substance, which at length firmly unites together the serous surfaces. This uniting substance becomes more and more dense, and not unfrequently resembles ligament in toughness and general aspect. In this form it may frequently be seen in phthisical cases, uniting together the lobes of the lung and pleural surfaces. Occasionally it assumes even a cartilaginous hardness, resem- 666 DISEASES OF THE RESPIRATORY SYSTEM. bling the fibro-cartilage of the intervertebral substance. In this state it may frequently be observed on the pleurae, and I have seen it thus half an inch thick, intimately uniting the lungs to the ribs. When it has been very slowly developed, it produces white indurated patches, of a glistening cartilaginous appearance, varying in extent, the surface of which has assumed the character of a serous membrane, and in no way interferes with the movements of neighboring organs. Such patches are exceedingly common on the sur- face of parenchymatous organs, as the lungs, heart, liver, spleen, and kidneys. Occasionally encysted ab- scesses of the pleura are resolved, and their walls contracting assume a cartilaginous hardness. Dr. Mark- ham has recorded a remarkable ex- ample where the pyogenic walls in this manner formed a tube sur- rounded by puckering of the pleura pulmonalis, the lung itself being quite healthy.* (Fig. 450). The hardish gritty particles scraped from its roughened inner surface consisted chiefly of cholesterine and granular matter. Lastly, false mem- branes on the pleural surfaces, but Fig. 450. especially on the costal one, may assume a stony hardness, from the deposition of calcareous matter; and patches of this character may be scattered over the serous membrane, or may exist in disseminated points. The minute structure of the coagulated exudation, composed of plas- tic or pyoid corpuscles and molecular fibres, has been previously de- scribed and figured, p. 165. These fibres are more and more aggregated together the more dense the lymph becomes, and, in cases of calcareous deposition, are associated with molecules and irregular masses of earthy salts, mingled .with crystals of cholesterine, and, it may be, numerous fatty molecules and granules. It results from our knowledge of the morbid anatomy of pleuritis, conjoined with careful observation at the bedside, that, if a large quantity of fluid be interposed between the pleurse, the respiratory murmurs will be lost, while the vocal resonance is diminished. If the amount of fluid be small, the murmurs are obscure, and the vocal resonance assumes a peculiar vibrating character, said to resemble the bleating of a goat. This is aegophony. If strings or bands of chronic lymph exist, which are stretched during the movements of the chest, then the rubbing sound will assume a leathery or creaking character; and if there be calcareous deposition, a filing or grating noise may be produced, although this is * Patholog. Soc. Trans., vol. ix. p. 51. Fig. 450. Remains of a pleural abscess.—(Markham). PLEURITIS. 667 very rarely heard over the pleurae. Not unfrequently dense adhesions, with thickening of the fibrous tissues uniting the pleurse, may occasion partial dulness, and increase of the vocal resonance, a result not uncom- mon at the apices of the lung, but which must be carefully distinguished from the condensation from tubercle. With regard to the treatment, it is essentially the same as that of other acute inflammations. It is rare that a case enters an hospital in its incipient stage, that is, when the serous membrane is unusually dry, and before much exudation has occurred. But in private practice such cases are more common, and occasionally they may come on in the ward of an hospital. At this early period, a general bleeding was formerly recommended, with a view of cutting short the inflammation, the possibility of which we have discussed at p. 306. When, however, exudation has been poured out to any extent, and has coagulated, bleeding is injurious, and we must endeavor to favor the development, absorption, and excretion of the exudation, by means of warm, topical applications, sudorifics, and diuretics. The urine especially should be carefully watched, as the sediments it contains will serve as an index to the amount of exuded matter excreted. Care should also be taken, at this period, not to allow the general strength to sink, for it is only by keeping up the nutritive functions that we can assist the vital powers in making those transformations which are essential in procuring the disappearance of the fluid, and adhesion of the solid exudation. By some, calomel is considered to be directly indicated as a means of favoring absorption from the serous cavity. It was fairly tried in Case CXLL, but was more productive of harm than of good; and although I have frequently seen the drug employed for this purpose, I have not met with a single instance where its good effects have been unequivocal. If there be much local pain, warm applications at first, and subsequently blisters, tend to remove it. On some occasions, when the exudation has been very abundant in the pleural cavity, and the vital powers of the economy are constitution- ally low, and have been depressed by injudicious antiphlogistic treatment or want of rest, the changes described do not occur. The exudation, in such cases, passes into pus, although some of the fibrous element attaches itself to and lines the membrane. This termination of pleuritis is denominated empyema. Case CXLIIft—Empyema, with Fistulous Openings between the Lung and Pleural Cavity, and between the Pleural Cavity and External Surface. * History.—George Fair, set. 30, a ploughman—admitted December 10th, 1850, in a very exhausted state. Fourteen months ago had acute pleuritis, on account of which he was confined to bed for eight weeks, and was bled several times. Three months afterwards he still felt occasional pain in the right side, which gradually became more constant and severe, and at length was accompanied by cough and ex- pectoration. He now perceived a small swelling below the right nipple, which, at the end of last July, was the size of a hen's egg. It was then opened by incision, and a quart of purulent matter extracted. About the end of August, two other apertures formed spontaneously in the neighborhood of the previous one. As soon as matter * Reported by Mr. J. M. Cunningham, Clinical Clerk. 608 DISEASES OF THE RESPIRATORY SYSTEM. was discharged from the external opening, the amount of expectoration was di- minished. Symptoms on Admission.—Thoracic walls much depressed under right clavicle; right side of chest motionless on taking a full inspiration ; three apertures still exist in the thoracic walls; the upper one (that made by the incision) is between the sixth and seventh ribs, immediately below the right nipple, the two others a little lower down, and somewhat smaller; from all three there is a copious purulent discharge. Circumference of the thorax, on a level with the right nipple, measures thirty-five inches ; from the spinous processes of the vertebrae to the sternum, on the right side, measures sixteen and a half inches, and on the left, nineteen inches. On percussion, the left side is resonant throughout; on the right side there is a dulness everywhere, but most marked in the inferior two-thirds; posteriorly, the dulness is not so marked as in front. On auscultation, the respiratory murmurs on the left side are puerile; under the right clavicle the respiratory murmurs are harsh, and the vocal resonance increased; a little lower down the respiratory murmurs become more feeble, and there is crepitation with the inspiration ; in the remaining lower two-thirds of the right front, the respiratory sounds are inaudible; over the whole right back, the respiratory murmurs are feeble; the vocal resonance increased and aegophonic; in the lower third crepitation is audible. Pain over the sternum and under right clavicle ; cough neither frequent nor severe ; expectoration scanty, partly white and frothy, partly tenacious and muco-purulent. Apex of heart beats feebly half an inch to the left of its natural position. Pulse 92, slightly jerking, but compressible ; general strength much reduced. Progress of the Case.—In the beginning of January, he was attacked with vomiting and diarrhoea, accompanied with febrile symptoms, which greatly diminished his strength; his countenance assumed a hectic appearance, and the opening in the thorax became painful and larger, their margins were inflamed and ulcerating, and the discharge continued. On the 11th, it was ascertained, by means of the probe, that of the three openings the middle one alone enters directly into the pleural cavity, and ad- mits with ease a No. 8 catheter ; the other two communicate with the central one underneath the integument. On the 29th, diarrhoea and purulent discharge from the chest had diminished, his appetite and general health were also improved, but he was removed from the house by his friends. The treatment consisted at first of good diet and tonics ; and when the vomiting and diarrhoea appeared, various remedies to check these symptoms. On the 18th of January, a small canulaand No. 8 catheter were in- troduced side by side into the opening into the pleura. By means of a Read's syringe attached to the former, about a pint and a hah0 of distilled water, at the temperature of 90°, was injected into the pleural cavity. The fluid escaped through the flexible catheter, but did not equal in amount what was thrown in, and was at length discharged clear and unmixed with pus. During the half hour immediately following the operation, a quantity of clear water oozed from the wound. Commentary.—When this man entered the house, his general strength was much reduced ; and it was apparent, from a careful study of the physical signs and symptoms, that a communication existed be- tween the lungs and pleural cavity, in addition to the external fistulous opening into the latter. The pleuro-pulmonary fistula had evidently formed before the opening through the thorax was made artificially, as evinced by the marked diminution of expectoration on the evacuation of pus externally. That it continued to exist, I was satisfied, by observing that the sputum was increased when the external discharge diminished, and vice versa. Two errors had been made in the previous treatment. These consisted,—1st, In the " frequent bleedings," which had so dimin- ished the general powers of the system, as to have checked those changes in the exudation necessary for recovery ; 2d, In making a free incision, instead of a small puncture, to draw off the purulent matter. Of these two errors, the first, however, was the greatest; indeed it was irremedi- able. The second was probably undertaken with the idea formerly so prevalent, that pus is injurious to the economy, and when known to exist should be let out as soon and as freely as possible. We now know PLEURITIS. 669 *hat there is nothing to be feared from the mere presence of pus, either in the lung or pleural cavity ; and that the most natural method for its disappearance is by absorption and elimination. Still, when large in amount, and either pointing externally, or displacing the heart internally, no danger can arise, from making a puncture with a small canula, and allowing the matter to flow out, while we prevent air from passing in. Indeed there is every chance of producing benefit, for we thereby save the vital powers a considerable amount of unnecessary work, and so facilitate the disappearance of the exudation and return of expansion in the compressed lung. With regard to the operation of paracentesis thoracis, and the good effects attending it, 1 refer you to some excel- lent papers by Dr. Hughes,* and a lecture by Dr. Alison.f (See also p. 675.) In the case before us, the difficulty experienced was to rally the general strength, especially after it had been so much reduced by diarrhoea, and this was to some extent accomplished. My attention was then directed to the cure of the thoracic disease ; and it occurred to me that if the pus could be replaced by water, there would be less labor thrown upon the weakened absorbing surfaces. The pleural cavity, therefore, was washed out with distilled water, heated to 90° as di- rected ; and this would have been repeated at intervals, had he not left the house, and thus put an end to every effort undertaken for his benefit. Case CXLIII.J—Chronic Pleuritis and Pneumo^lwrax, without Symp- toms—Articular Rheumatism—PericarditTs—Recovery. History.—William Dow, aet. 33, boot-maker—admitted 26th of January, 1857. States that he has always been a temperate man up to his present illness, and has had pretty good health. On the 12th of last December, after exposure to cold and damp during the day, he was seized with articular pains, which affected most of the joints, and have continued to wander from one to the other up to the present time. On the evening of the 7th of January, independent of any exertion, the patient was suddenly seized with acute pain in the umbilical region, attended with difficulty of breathing; these symptoms were at once removed on taking a powder, which caused the expulsion of much wind. He denies ever having had cough, pain in the side, or any pulmonary symptoms whatever. Symptoms on Admission.—On inspection of the chest, there is less expansion on the right than on the left side anteriorly ; posteriorly, the right side bulges consider- ably below the level of the third rib ; the measurement of th e corresponding sides is slightly different; the girth of the left side being fifteen and a half, that of the right sixteen inches. The movement of inspiration on the right side is very slight; on the left the girth is increased half an inch on a full inspiration. Percussion note over the right side, anteriorly, is tympanitic from apex to base, being flatter at Ihe apex. It likewise extends on a level with the nipple over the left side to about half an inch beyond the sternum. On auscultation, there is a slight harshness of re- spiratory murmurs at the apex of left lung, the sounds of which are otherwise nor- mal. On the right side, the vesicular murmur is supplanted by loud amphoric breathing, more distinct towards the base. Expiration is much prolonged. In the recumbent posture, both inspiration and expiration are accompanied by a clear pro- longed metallic note, exactly like the distant blast of a trumpet, somewhat louder with expiration. Vocal resonance over the middle third is of a loud brazen metallic character. Posteriorly on this side, percussion superiorly is tympanitic, but below second dorsal spine, dulness commences, becoming more intense as it extends to the * Guy's Hospital Reports, vol. ii. Second Series, f Monthly Journal, August 1850, % Reported by Mr. T. J. Walker, Clinical Clerk. 670 DISEASES OF THE RESPIRATORY SYSTEM. base of the lung. Laterally its extent is bounded by a line drawn vertically fron the posterior fold of the axilla. At the apex, inspiration is blowing, with prolonged expiration, and at the close of inspiration a moist click is heard. Towards the baa;, the respiratory sounds are scarcely audible, and inspiration is accompanied with an obscure crepitation (?). Vocal resonance at apex and base is aegophonic, but over the middle third it is normal. No cough, expectoration, dyspnoea, pain, or other pul- monary symptoms. Impulse of heart's apex felt in the usual position. Transverse dulness and sounds normal. Pulse 108, feeble. Patient is somewhat deaf; has still pain in both knee and ankle joints, and in the right shoulder and carpo-phalangeal joints. Tongue dry and furred, otherwise normal. Copious deposit of lithates in the urine. He is much emaciated, and for the last seven weeks has perspired very freely. Habeat Pulv. Doveri gr. xij. hord somni sicmenda. Progress of the Case.—January 28th.—Pain in the joints is now so much re lieved, that he can move the limbs with comparative freedom. He slept well last night. R Potass. Nitrat. ; Potass. Bicarb, aft 3 ij : Aquam ad § vj. M. Capiat § ss ter indies. Jan. 29th.—On examining the patient to-day, Dr. Bennett found that, while lying on his left side, percussion note was duller over the sternum than when he lay on his back, and the slightly dull tone over the right lateral region became clear. When also the patient is placed in a sitting or recumbent posture, dulness extends from the back forwards to the centre of the right lateral region, and upon being laid on his left side, the posterior part of the lateral region becomes resonant Jan. 3lst. —Physical signs over right side of chest continue as before. Apex of cardiac organ beats with a visible impulse somewhat to the inner side of a line, vertical from the nipple between the fifth and sixth ribs. At the margin of sternum a double rumbling sound is audible, not quite synchronous with the systolic or diastolic movements. Transverse dulness of heart on percussion still two inches. Pulse 100, small, rather hard. Respirations twenty-two. Feb. 2d.—Friction murmurs at the base of the car- diac organ more audible ; the patient has no pain over pericardium, nor uneasiness, except after cough, over the chest generally; feels very slight tenderness on percus- sion over the sternum at the level of fifth and sixth ribs. To have spongio-piline, sa- turated with warm water, applied over the precordial region. Feb. 5th.—Patient so well as to get up in the morning, and from this time he rapidly regained his strength. The pulmonary signs have undergone no change. The friction murmurs over the heart gradually diminished, and disappeared on the 12th, while a blowing murmur was gradually established, heard loudest with the first sound over the apex. He was dismissed March 11th. June 22d.—He was re-admitted to-day, having in the interval again lost strength in consequence of his work being too fatiguing, and his appetite having failed him. The amphoric respiration, metallic notes, and brazen resonance of voice, have now disappeared from the right side, which is dull on percussion, immovable during inspi- ration, with slight trace of respiratory murmur, and great increase in the vocal reson- ance. Left lung healthy, with puerile respiration. Still a blowing murmur with the first sound of the heart, loudest at the apex. To have nutrients, with § iv of wine daily. July 28th.—Since last report his general health has been improving, and he now looks fat and well nourished, and says he is much stronger. Has no pain, cough, dyspnoea, or inconvenience of any kind. There is now decided flattening anteriorly over the upper third of the right chest. On deep inspiration it expands much more than formerly. It is still everywhere dull on percussion, with great increase of vocal resonance amounting to bronchophony anteriorly, and pectoriloquy posteriorly and superiorly. Respiratory murmurs are absent over upper third of lung, but inferiorly and anteriorly inspiration is audible but feeble, and posteriorly is much stronger. Discharged. Commentary.—It is no uncommon thing for men who have pre- viously had pleurisy, to be seen walking about the streets with one side of the chest more or less dull on percussion and incapable of action, although complaining of nothing. But this, .so far as I am aware, is the only instance on record where a pleurisy has come on and proceeded to the formation of extensive pneumo-thorax, not only without symptoms, but without the cognizance of the patient. Yet such is the case before us. For when I demonstrated to the clinical class at the bed-side the PLEURITIS. 671 tympanitic sound over the right chest on percussion, the absence of healthy respiration, the metallic notes with the respiratory murmurs, and the brazen amphoric vocal resonance, he himself denied that there was anything wrong with his chest, and smiled at the trouble we gave our- selves in examining it. In his case, as in Case CXL., after the acute rheumatism subsided, we had the greatest difficulty in keeping him in the house for the purpose of observation. On his going out, however, he himself at length became satisfied that his breathing was not so good as it ought to be, and on his re-admission subsequently we had the pleasure, under the influence of nutrients, to see the morbid murmurs disappear, the chest gradually contract, and his general health re-establish itself. What might have been the consequences, if by means of physical signs we had not detected this morbid condition, but had dismissed him from the house as soon a3 he had recovered from his rheumatism, cannot positively be said; but judging from what followed, I have myself no doubt that he would rapidly have sunk exhausted. I saw him several times after his first dismissal, and he was only supported by the most energetic use of nutrients and wine. Case CXLIV.*—Empyema, following Chronic Phthisis—Paracentesis Thoracis—Pneumo- Thorax—Singular mode of Death from Enor- mous Distention of the Stomach and Emphysema of its Coats— Tubercular Pleuritis—Adherent Pericardium— Waxy Spleen— Tubercle in the Kidneys. History.—Allan Brown, ast. 26, a gilder—admitted November 26, 1856. States that about twelve months ago, he suddenly at night, experienced pains about the heart in drawing breath, together with shivering and febrile symptoms. For three days the pain was acute; it then disappeared, to come back however at different times, lasting for a day or two, and then disappearing again. During the six months pre- ceding this attack, he had had a short, and, for the most part, a dry cough, with frothy, white, and gelatinous sputum. This has continued ever since ; and on one occasion, eight months since, he spat up blood. Six months ago he noticed the left side enlarging; two months afterwards he became unfit for work, and also unable to lie in bed on the right side. About this period he was subject to profuse sweatings, which have since gradually declined. His appetite, at no time great, has become yet more defec- tive, especially during the last few months. His thirst has always been considerable. Symptoms on Aomission.—There is marked depression of the right chest under the clavicle. On the left side, there is a bulging in the mammary region outwards and forwards. Posteriorly there is a general protrusion of the left side of chest infe- riorly, and fulness of the intercostal spaces, but to no great extent, except at the extreme base and over the lumbar region, where there is fluctuation and extreme ten- derness on pressure, with redness and increase of temperature. The chest measures— Level of Four inches Nipple. lower. Leftside...... 18 17 Right side ...... 18$ 16$ This examination was conducted throughout while the patient was in the sitting posture. During respiration there is an expansive motion on the right side, espe- cially under the clavicle and hi the infra-axillary region, but on the left side there is no corresponding motion. There is also slight vocal fremitus on the right side, but none on the left. On percussion there is absolute dulness on the left side anteriorly, laterally, and posteriorly. On the right side anteriorly there is comparative reson ance, but not loud nor clear, down to the level of the third rib. Below that level, over a region in which the cardiac pulsation may be felt, there is dulness. Laterally and posteriorly the percussion is good. On auscultation on the right side anteriorly down to the level of the third rib, also laterally and posteriorly, the respiratory mur- * Reported by Mr. H. N. Maclaurin, Clinical Clerk. 672 DISEASES OF THE RESPIRATORY SYSTEM. murs are dry and somewhat blowing in character and intensified in tone. On the left side no respiration is audible, except near the sternal end of the clavicle ante- riorly and near the inferior angle of the scapula posteriorly. In these regions the respiratory murmur is heard faintly. Vocal resonance is greater over right apex, and posteriorly over the whole side, then over the corresponding left. There is great dyspncea, so that the patient frequently cannot answer questions until he recovers breath. The cough is short, shallow and gasping, and when excited continues for a considerable time, the patient's face becoming flushed. Sputum is scanty, and expectorated with difficulty. The cardiac impulse is between the fifth and sixth ribs on the right side, an inch and a half below and to the outside of the right nipple. Cardiac sounds healthy. Pulse 130, small and weak. At this stage of the exami- nation the patient became much troubled with spasmodic cough, so that further inter- rogation was considered unadvisable. To have § iij of wine, steak diet, extra milk and an egg for breakfast. Progress of the Case.—On the 8 seven died; nine were relieved one or many times; but they had either a long and tedious illness ter- minating usually in phthisis, or a fistulous opening, or a still doubtful result. A sanguinolent fluid at the first puncture (and by that I mean a dark red thin fluid evidently stained with blood, though not coagulating) I consider almost certainly fatal, and a consequence of some malignant disease of the lung or pleura. There were seven of such cases. In six the patients died. In one there was a doubtful result, but apparently fatal tendencies were commencing. If the fluid is found sanguinolent at the second or any subsequent puncture, I deem it of comparatively little importance towards the prognosis. A mixture of bloody purulent fluid at the first operation is usually fatal. Three cases, all fatal, occurred. A fetid gangrenous fluid is very rare, only one case having occurred, and that fatal; but in this case infinite relief from horrible orthopncea was obtained, and it never returned, though the patient sunk and died in a few days. Gangrenous pleura was found. I have operated once in pneumo-hydrothorax with temporary relief and comparative ease for several days. Many theoretical objections may be urged against the operation in such a case. To such objections I have simply to answer that, as the operation can do no harm and may give much relief, I shall operate again in any case where the dyspnoea may be so great as to require it. Finally, in seven cases I got no fluid. These cases occurred usually in the earlier operations, and the failure was often owing, I have no doubt, to the cautious and slow manner with which I plunged the t trocar between the ribs, carrying thus the false membrane of the pleura costalis before the instrument instead of piercing it; so that a valve was really formed over the end of the canula. At other times I have little doubt that an error of diagnosis was made, and that instead of a fluid there was simply an unexpanded lung and thick false mem- branes on the pleura, causing as much dulness on percussion and absence of respira- tion as a fluid would have done. The differential diagnosis of the two was not, at first, quite so easy as it is now. Inspection usually is the test between the two conditions; the intercostals being distinct, and depressed when a membrane exists; but very in- distinct and level with the ribs, or, possibly prominent, when a fluid occupies the chest. Once an immense tumor occupied and uniformly distended one pleural cavity, and in its course presented all the phenomena, natural and physical, of simple pleurisy. I tapped three times—viz., at the back, side, and front, at the same visit. No evil followed." " Of 25 cases, 14 were of the right side, 11 of the left. Of the 14 of the right side, only one person is mentioned as having tubercles, and in that the pleurisy was cured and the pulmonary symptoms mitigated. Of the 14 persons tapped in right side, 28"5'7 per cent died; 64-28 per cent were cured, and 7"14 per cent remained doubt- ful. Whereas, of the 11 cases of the left side, 45-45 per cent died, 36'36 got well, 18-18 were doubtful. In other words, twice as many have got well from tapping the right as the left; and only half as many have had doubtful results from operations on the right, as in those where the left side has been tapped. Hereafter, if my cases are any criterion wherefrom to judge, I shall regard an operation on the right side as much more favorable than one on the left; which I can hardly think would be the case were all right side pleurisies tuberculous. Experience teaches me to operate in every case, however recent or chronic may be the attack, provided there is per- manent or occasional dyspnoea of a severe character, evidently due to the fluid. I have, of course, more hope of doing good where the disease has not been of too long duration, is uncomplicated with phthisis, or any other disease, and where, moreover, * American Journal of the Medical Sciences, January 1863. PLEURITIS. 677 the amount of fluid seems directly the cause of the trouble. I also deem it best to operate in any, even latent cases, where the pleural cavity gets full of fluid; and if, after a reasonable amount of treatment, the fluid does not diminish. The point originally chosen by Dr. Wyman and myself—viz., in a line let fall from the lower angle of the scapula, and between the ninth and tenth ribs—I deem the most appropriate point at which to make a puncture. I have, however, tapped under the axilla, or in the breast, where the case seemed to require it. In selecting the precise intercostal space, on the back, I usually choose one about an inch and a half higher than the line, on a level with the lowest point at which respiratory murmur can be heard in the healthy lung of the other pleural cavity. I never wait until pointing commences; for then I am sure that pus will be found. If pointing without opening has commenced, I do not necessarily tap in that place, as recommended by the older surgeons, but seek the most depending point in the chest. While thus desiring to operate before a local distention shows itself, I dislike or refuse to tap where there is contraction of the intercostal muscles; and I am certain of getting fluid only where there is distention or flattening of the same." As to any objection whatever to this operation, he admits of none. It so happened, that in the winter session 1862-63, two cases of chronic pleurisy of the left side entered my wards, in both of which the heart was forced over into the right chest. The whole question as to thoracentesis was then carefully discussed ; and as the result was curious, I give these cases shortly, with the commentary they elicited :— Two cases of Chronic Pleurisy, with fluid in the left chest, forcing the heart into the right thoracic cavity. Recovery of the first; no chanye in the second. Case CXLV.*—William M'Gregor, a?t. 25, a malster—admitted December 22d, 1862.—Two months ago he experienced stitching pains in the chest, but continued to work until fourteen days ago, when the breathing became so difficult he was obliged to desist. With the exception of slight cough, has had no other symptom— no pain, no fever. On admission the left chest bulges more than the right, and measures three-quarters of an inch more from sternum to spine. It is completely dull on percussion from the apex to the base, with absence of respiration everywhere, and pealing resonance of the voice posteriorly over lower angle of scapula. Right chest resonant on percussion; breathing puerile, but otherwise healthy. The heart's impulse is felt between fourth and fifth ribs, on right side, two inches from the sternum. Its area of dulness extends across two inches to the right of that bone; sounds normal. Pulse 58, regular, and of good strength. Other functions healthy. Ordered a mixture of Sulphuric Ether, Chlorodyne, and Squill mixture, which was discontinued in a few days, when all cough, as well as his other symptoms, had dis- appeared. Steak diet, with § iv of wine daily. January 3d.—A clear note is elicited on percussion below the left clavicle, extending down to the fourth rib, and in this clear spaee the breath-sound is audible. This clear space gradually extended, so that on the 14th of January it had extended a little below the nipple; and the apex of the heart was felt beating immediately to the left of the sternum. Jan. 26th.—He insisted on leaving the Infirmary, considering himself quite well. His strength and healthy appearance have returned. The left lung is evidently expanding daily, and the heart returning to its normal position. Case CXLVI.f—William Dunlop, aet. 20, a confectioner—admitted December 12th, 1862.—Caught severe cold, with pain in his left chest, nineteen months ago, on board ship, when returning from the East Indies. He had great difficulty of breathing, and was confined to bed for a fortnight. Six months afterwards, on arriving iu Greenock, entered the Infirmary there, and, in addition to other treatment, had 3-J pints of clear fluid drawn off from his chest, which produced temporary relief. Dyspnoea, however, soon returned, and has continued up to his admission. He now complains of constant palpitation. The apex of the heart beats between the fifth and sixth ribs on the right side, 1$ inches to the inside of the nipple. There is com- plete dulness on percussion over the whole of the left chest, while on the right side the tone is normal. On left side also there are no breath-sounds, nor vocal resonance * Reported by Mr. Michael Beverley, Clinical Clerk. \ Reported by Mr. T. Clark Wilson, Clinical Clerk. 678 DISEASES OF THE RESPIRATORY SYSTEM. audible, except over root of left lung posteriorly, where there is loud bronchophony Respiration on right side exaggerated, but otherwise normal. Has difficulty of breathing on taking any exertion, and a slight cough. Left chest measures a quarter of an inch more than the right from sternum to spine; other systems normal. To have steak diet, and § ii of wine daily; Habeat Potassa; Bitartratis 3 ss ter indies. The treatment was continued until 27th December, when diarrhoea supervening, the Pot. Bitart. was stopped. Feeling his symptoms then somewhat relieved, he wished to go out, and did so on 7th January; his physical signs, dyspncea and palpitation on exertion, having in fact been in no way improved. Commentary.—It is seldom that two such cases are to be found in a clinical ward at the same time. Neither of them presented any urgent symptoms calling for thoracentesis; and in discussing the treat- ment, it was strongly urged upon me by the examining class to try the effects of diuretics, which at the time were stated to have been highly successful in some other wards of the hospital. I consented to the proposal; and as the two cases appeared to be very much alike, it was agreed to treat one by diet alone, and the other, in addition to diet, by 3 ss doses of the. supertartrate of potass. The result was that the one treated by diet alone recovered, the fluid disappeared from the chest, and the heart returned to the left side, while the other, who, in addition to diet, took diuretics, underwent no improvement. Of course such result was altogether accidental, but there is this caution to be derived from it. Let us suppose the treatment had been reversed in the two cases, we should scarcely then have freed ourselves from the conclusion that the diuretics had produced the marked recovery which occurred. Again, if thoracentesis had been performed on the first case, we should have thought it was the cause of recovery, Such, among many others, are the difficulties which present themselves to just conclusions in therapeutics; and indicate strongly how necessary it is that such con- clusions should be based upon a large number of well-observed facts. Several other cases of chronic pleurisy of great interest have entered the clinical wards. That of Garvie * will be remembered with interest by the summer clinical students of 1862, in whom, suddenly after coughing, there was elicited a remarkable metallic echo and resonance, like that of striking a gong; and that of James Robertson, f admitted in May 1864, where a circumscribed cavity in the right chest, sometimes filled with pus and at others with air, was carefully diagnosed, and all the views regarding it derived from physical examination were con- firmed by the examination after death. PNEUMONIA. Case CXLVII. J—Pneumonia on Right Side and slight Pleuritis— Recovery. History.—Roderick M'Farlane, set. 20, a gardener of healthy and robust constitu- tion—admitted December 17th, 1856. On the 12th instant felt unwell, with a sensa- tion of cold in the back. On the 13th had pain in the right infra-axillary region, increased on deep inspiration, with hot skin, headache, thirst, and loss of appetite, symptoms which have continued ever since. On the 14th, cough appeared with scanty expectoration. Has taken a dose of castor-oil and some pills. Symptoms on Aomission.—Expansion on both sides of chest equal. Respirations twenty-four in the minute, not labored. Can lie on either side, but prefers lying * Reported by Mr. B. B. Thurgar, Clinical Clerk. f Reported by Mr. G. F. Fulcher, Clinical Clerk. \ Reported by Dr. J. Glen, Resident Clinical Physician. PNEUMONIA. 679 on the back. Pain during deep inspiration over right infra-axillary region; slight cough; scanty expectoration—frothy and mucous. On percussion, cracked-pot re- sonance extends from clavicle to fifth rib on the right side. Below this level percussion is dull. There is also decided dulness posteriorly from spine of scapula to base. Else- where percussion natural. On auscultation, puerile respiration over left front; ovef right front superiorly respiration is harsh, without rale ; below fifth rib, it is suppressed. Posteriorly over two lower thirds, double friction is audible, with fine crepitation at the close of inspiration; on left side occasional sibilus, with a few moist rattles at close of inspiration over lower third. The vocal resonance is increased and sharp on right side anteriorly, but greatly increased and asgophonic posteriorly over area of dulness. Pulse 104, incompressible and full. Skin hot and dry. Tongue in centre brown, dry, and cracked; edges moist and clean. No appetite ; great thirst; bowels always regular, but have been opened by laxatives. Urine natural. Other functions normal. R Sol. Antim. Tart. 3 ss ; Aquae Ammon. Acet. 3 j ; Aquae | viss. M. Habeat sextam partem quartd qudque hord. Progress of the Case.—December 18.—Grazing friction audible over the right infra-mammary region. Crepitation distinct over right back inferiorly. Pulse 120, soft. Sputum scanty, consisting of orange-colored gelatinous masses. Otherwise the same. Dec. 20th.—Crepitations very coarse over right back. Fever abated. Tongue moist and clean. Pulse 72, of good strength. Temperature of skin natural. Omitt. mist. Dec. 22d.—Crepitation and friction disappeared from right back. Abundant sediment of lithates in the urine. R Sp. jEther. Nit. 3 iij ; Vin. Sem. Colchici 3j. Aquam ad § v. M. Two table-spoonfids to be taken every four hours. Dec. 24th.— Dulness over right back and cracked-pot sound anteriorly greatly diminished. For the last three days has had profuse diaphoresis. Urine again natural. Omitt. mist. To have steak diet. Dec. 26th.—No dulness anywhere ; respirations natural. Is quite re- covered ; but as the weather was severe, and he had to work immediately in the open air, if dismissed, he was not discharged until January 2d. Commentary.—This young man was first seized with illness on the 12th of December, and was admitted on the 17th, when hepatization of the lung was found to have occurred in the lower two-thirds of the organ on the right side, combined with slight pleuritis. Fever was well marked, the pulse full and incompressible. On the 22d, the exudation was thoroughly softened and passing off from the economy principally by the urine, but partly by the skin. On the 26th, all trace of the disease had disappeared. The treatment consisted at first of slight salines and rest, then of a diuretic mixture to favor excretion of the effete products by the urine, and lastly of steak diet. From the first commencement to the complete disappearance of the disease was fourteen days; and to the abatement of fever and commencing resolution, eight days. The febrile phenomena in this case were un- usually well pronounced. The pulse was full and incompressible—in fact, hard; the skin hot and dry. Tongue furred and dry ; no appetite; great thirst, etc. In short, this young vigorous lad presented all those symptoms in which we are instructed by most writers to bleed, and in which it has been argued, that without bleeding a fatal suppuration was likely to occur. I need scarcely add, that the propriety of such prac- tice, as well as the probable fatality, were alike negatived by the result. Case CXLVIIT.*—Double Pneumonia, with urgent Symptoms, and full. strony Pulse—Pleuritis on Left Side—Recovery in Nine Days. History.—John M'Farlane, set. 30, a railway laborer—admitted Nov. 12, 1858 Has been subject to a slight cough and expectoration, sometimes tinged with blood, for the last ten winters ; otherwise he has enjoyed good health. On Nov. 9th, whilst working on a railway bank, which was much exposed to wind and cold, he was sud- denly seized with great pain in his lower extremities ; he, however, continued at his work, till the evening, when he experienced a sharp pain in his left side, with diffi- * Reported by Mr. Arthur Garrington, Clinical Clerk. 680 DISEASES OF THE RESPIRATORY SYSTEM. culty of breathing, and general febrile symptoms. He went to bed ; and on the lOtb, feeling no better, he sent for a medical man, who ordered a blister to be applied to the left side ; he also gave him a powder, and a mixture which made him very sick. The pain was slightly relieved after the application of the blister, and he felt much easier on the 11th, but on the 12th the pain increased, while the difficulty of breathing and of expectorating became so bad that he was brought into the Infirmary. Symptoms on Admission.—His face was much flushed ; skin hot and dry; tongue moist, and with a white fur ; great thirst; pulse 95, full and regular; urine oran°-e- colored, with a copious sediment of urates, only a slight .trace of chlorides, and a trace of albumen. His respirations were quick and labored Expectoration very tenacious, with numerous rusty-colored masses in it. Cough frequent and painful. On the left side anteriorly percussion was good, but crepitation was heard all over the front with the exception of a space 2$ inches below the clavicle, where the respiratory sounds were very harsh. Posteriorly on this side there was marked dulness from the spine of the scapula to the base of the lung, over which space loud crepitation was heard, and peal- ing vocal resonance, more especially about the centre of the lung. On the right side anteriorly there was slight comparative dulness over a space extending from the clavicle two inches downwards. Posteriorly on this side there was slight comparative dulness at apex, where expiration was prolonged, and the inspiratory murmur harsh. R Pulv, Doveri gr. x, to be taken immediately. R Sol. Antim. % j; Potass. Acet. § ss; Aquam ad § viij ; Ft. mist. Two table-spoonfuls every four hours. Progress of the Case.—Nov. 13th.—Passed a sleepless night. Cough incessant, and dyspnoea urgent; face livid. Pulse 112, full and strong; sputum very copious rusty and gelatinous. In addition to physical signs formerly reported, there was faint crepitation all over right back posteriorly (most distinct at apex), but no great increase of vocal resonance; friction over left side anteriorly below nipple, both with expiration and inspiration, but loudest with former, and posteriorly marked dulness over inferior two-thirds, with loud crepitation and bronchophony. Ordered to be cupped to § v over region of pain on left side, and to take only one table-spoonful of the mixture, to which is to be added Sp. uEth. Nitr. 3 ij- To have strong beef-tea and milk. Nov. \4th.— Patient says he felt relieved by the cupping for 3 or 4 hours, but the pain returned af- terwards as bad as before. There is still great dyspncea and lividity of face; expec- torates about 18 oz. of purulent, gelatinous, frothy matter, tinged with rusty-colored blood, during the 24 hours. Pulse 98. soft and irregular. To have a table-spoonful of wine every hour. Omit mixture. Nov. 15th.—Dyspnoea and pain in side much di- minished. Sputum less rusty. Pulse 100, strong and regular. Very coarse crepita- tion (amounting to mucous rattles) heard over left side anteriorly. Respiratory mur- murs harsh and dry over right side anteriorly. There is still marked comparative dul- ness over left back, and also in upper third of right back. Tubular breathing over up- per fourth of right back, harsh inferiorly. Crepitatron over left back, but more feeble than before. Vocal resonance the same. Urine quite clear, and no deposit. Chlo- rides have been increasing since the 13th, but are not yet in normal proportion. Still thirsty and feverish. R Sp. JEth. Nitr. 3 iij ; Potass. Acet. fss. Aquam ad fyj; Ft. mist. To be taken as before. To continue the milk, wine, etc., and to have 6 oz. of beefsteak. Nov. 18th.—Patient says he feels very much better. All crepitation gone, but there is slightly increased vocal resonance on left side. Urine loaded with urates. Convalescent, but steak to be increased to 8 oz., and wine to be diminished to § iv daily. Nov. 24th.—Has been gradually getting stronger since last report. Yesterday he got up for some time, walked about the ward, and exposed himself to draughts in the pas- sages. This led to an attack of acute rheumatism, for which he was again confined to bed, and ordered Potass. Bicarb. 3j three times a day. He gradually got better, and was quite free from muscular pains on Dec. 4th; he got up on the 7th, and with the exception of slight weakness, felt quite well. 2 oz. extra beef-steak were ordered on the 11th, and he left the Infirmary on the 13th in perfect health. Commentary.—This is what some former writers would have called an " exquisite " case of pneumonia, occurring in a man who, with some emphysema, was accustomed to have attacks of bronchitis and bloody expectoration every winter. It presented all the symptoms of the disease, including pain in the side, great dyspnoea, lividity of the face, strong and full pulse, with copious rusty sputa. Physical signs also proved it to consist of hepatization of the two inferior thirds of the PNEUMONIA. 681 left lung, and of the superior half of the right lung. Occurring in the year 1858, it disposes of two theoretical statements which have of late been much discussed, viz.—1st, That such cases are now not to be met with; and, 2d, that if they should occur, bleeding would again be re- quired for their treatment. In this respect the case resembles that of Roderick M'Farlane, Case CXLVII.; and in severity that of Peter Robertson, Case CXLIX. In consequence of the dyspnoea and evident engorgement of the right side of the heart, he was cupped, and § v of blood extracted, with the effect of relieving his symptoms, but for a time only, as they returned with equal intensity in a few hours. This is the result which usually followed large venesections, and which misled practitioners as to its utility. I have no doubt that a large bleeding in this case, if it had not proved fatal, would have seriously prolonged his recovery, which took place under an opposite treatment on the ninth day. The case inculcates another caution—viz., the necessity of avoid- ing exposure to cold during convalescence, as in the debilitated condition which then exists there is very likely to be a relapse, or some other form of febrile disease, again proving that these are the results of weak- ness rather than of strength. Case CXLIX.*—Double Pneumonia—Great Dyspncea—No bleediny— Local warmth and Stimulants—Rapid Recovery. History.—Peter Robertson, set. 51, a tolerably robust man, house-painter—admit- ted May 11, 1857. On Tuesday last, the 5th instant, when washing the outside of a house, he got wet through from the dripping of water. In the evening had a rigor, which continued more or less all night. On the following morning had a short cough, and a thick yellow sputum. These symptoms continued the two following days, with pain in the left breast anteriorly; but he continued at his work, although feeling very weak. On the 9th he was obliged to go to bed, and observed his sputum to be tinged with blood. Yesterday again had rigors, with cramps in the arms and elbows. Symptoms op Aomissiox.—On percussion there is marked dulness over the lower two-thirds of the left lung posteriorly, with tubular breathing and coarse mucous rale on inspiration. The vocal resonance is segophonic inferiorly, and bronchophonic over the middle third. Right side and anterior surfaces normal. Sputum copious and viscid, mixed with dark blood. Pulse 100, small and weak. Respirations 36 per minnte. Skin moist. Other functions normal. R Liq. Ammon. Acet. 3 j ; Sp. JEther. Nitric. 3 S3; Vin. Antim. § jss: A quam ad § vj. M. One table-spoonful to be taken every three hours. Progress of the Case.—May 12th.—Dulness on percussion over lower third of right back, in addition to that on the left, with tubular breathing and increased vocal resonance. Physical signs otherwise the same. Respirations are 40 in the minute, laborious and catching. Sputum gelatinous and rusty. Pulse 120, weak. Face livid, and expressive of great anxiety. Urine high colored, scanty, and deficient in chlorides. Warm fomentations to be applied over left side, and to have 3 iv of wine. May \3th.—Much better. Respiration easy. No lividity or anxiety of countenance. Cough diminished. Pulse 80, soft, but of good strength. Omitt. mist. May 14th.— Less dulness and crepitation on left side ; on right side crepitation fully established. Chlorides present to a slight degree in urine, and urates abundant. Pulse 74, regular. Appetite returning. Tongue clean. May\6th.—Is now convalescent Urine natural. Percussion resonant over both backs; inspiratory murmurs heard, but no moist rales. Cough painless. Still gelatinous sputum without blood. Has been out of bed, and feels tolerably strong. Steak diet. May 19th.—Has been up all day, and says he is quite well. May 20th.—Dismissed. Commentary.—This was a severe case of double pneumonia, with great dyspnoea, impending suffocation, and great weakness on the seventh * Reported by Mr. W. H. Davies, Clinical Clerk. 682 DISEASES OF THE RESPIRATORY SYSTEM. day, when wine was liberally administered. On the following day he was better, and continued to improve, so that on the fifth day after admis- sion he was fully convalescent, and on the ninth was quite well, and re- turned to his work. I never saw a case in which the symptoms were more urgent than in this man the day after his admission, and in which the livid and anxious countenance, the intense dyspnoea, the bloody sputum and feeble pulse, gave stronger evidence of impending dissolution. A question arises whether, if this man had been bled, he would have been relieved. I think this is very probable. But it appeared to me at the time, that the practice would have been fatal. Certain it is, that by following an opposite treatment of warm fomentations locally, and wine internally, these symptoms quickly subsided, and next day he was found breathing easily, and from that moment, though both lungs were affected, speedily recovered. In a similar case, recently published by Dr. Mark- ham, a bleeding of § xvj caused marked and immediate relief, and on this ground the practice of bleeding is again inculcated. Now, everything in such a case depends upon the character of the pulse and amount of exhaustion—two points not referred to by Dr. Markham. It is to be observed, however, that whilst the above case, with the same impending dissolution from asphyxia and double pneumonia, was convalescent in five days after entering the house, and left the hospital quite well on the ninth day, Dr. Markham's case, though relieved by bleeding, had a long convalescence, with,pericarditis and pleuritic abscess.* Case CL.f—Pneumonia on the Right Side—Early Bleediny—Slow Recovery. History.—James M'Quair, tailor, ast. 29—admitted June 4th, 1855. This man has been of intemperate habits during the last five years. On the 28th of May, after severe drinking and exertion, followed by exposure to the night air, he was attacked early in the morning with rigor, chilliness, a feeling of weight over his whole body, and a dull heavy pain in the right chest. He drank several glasses of whisky and water to allay his thirst, and kept his bed, occasionally vomiting, and going out of doors to stool, until the 30th. He now felt very feverish, weak, and unwell, and a soup-plateful of blood was extracted from the arm ( 3* xxiv). Venesection to the same amount was made on the following day; but the pains in the side, with Sanguineous cough and expectoration continuing, he came to the Infirmary. Symptoms on Aomission.—On admission, the patient has an anxious and flushed appearance, and feels very weak. The respiration is hurried, 42 in a minute, and the lower part of the right lung expands little. Cough is short, frequent, and suppressed; the expectoration scanty, consisting of gelatinous mucus, slightly tinged with blood. On percussion, there is marked comparative dulness over the inferior half of the right lung, but the upper half anteriorly, especially at the apex, though flat in tone, gives out a tympanitic and somewhat intestinal note. On auscultation, crepitation is audible all over the right lung, both anteriorly and posteriorly, and the vocal resonance is much increased over the dull portion. The left lung is normal. The pulse is 100, hard and incompressible. Heart normal. Tongue dry, and covered with a dark brown fur, and the teeth surrounded by sordes. Appetite gone; great thirst; the vomiting, which existed at the commencement of the attack, has now ceased. Abdo- minal viscera normal; bowels regular. Skin dry and hot to the feel. Urine high- colored and diminished in quantity, clear and without sediment. No trace of chlo- rides ; no albumen. Nervous system normal. R Antim. Tart. gr. iij ; Aqua; 3 vj; Solve. One ounce to be taken every three hours. Progress of the Case.—June 5th.—Says he feels better; pulse 90, full and * British Med. Journal, Feb. 4, 1865. f Reported by Mr. Robert Byers, Clinical Clerk. PNEUMONIA. 683 compressible, but in the evening it fell to 80, and became soft. June 6th.—Pulse 78, soft, breathing more easy. On percussion, the lower half of right lung is dull, but the upper half is resonant, with distinct cracked-pot sound. Fine crepitation audible over the whole of right chest. June 8th.—The whole of the right lung in front has become resonant on percussion; otherwise the same. Faint trace of chlorides in the urine. June 9th.—Chlorides abundant in the urine. June 10th.—Percussion re- sonant and equal over both sides of chest anteriorly. Under right clavicle, cracked- pot sound still audible. Crepitation much less inferiorly, but continues at the apex, with increase of vocal resonance. Posteriorly, percussion over right lung dull inferiorly, with loud crepitation, and segophonic resonance of voice. The patient feels much better, though weak. Respiration free. Pulse 72, soft and regular. Con- siderable diaphoresis. Urine deposits on cooling a large amount of lithates. R An- tim. Tart. gr. ij ; Tinct. Camph. co. 3 ij ; Decoct. Serpent. § xij. M. 3* j- & be taken every three hours. June 14th.—Physical signs of right lung, with the exception of cracked-pot sound, much diminished. Has been taking, during the last three days, good diet, with 3 iv of wine. From this time he improved slowly, the crepitation and dulness posteriorly gradually disappeared, but the cracked-pot sound continued with great intensity up to the 29th of June, His strength was not sufficient to admit of his discharge until the 3d of July. Commentary.—This was a case in which nearly the whole of the right lung became pneumonic, and where we had an opportunity of convincing ourselves that full and repeated bleeding, although practised so early as the second and third days, had no beneficial influence on the progress of the disease. It should also be remarked, that these bleedings were practised in accordance with the rules laid down in systematic writings, that is to say, not only early, but when the pulse was accelerated, hard and incompressible, with all the characteristic symptoms of the disease. Surely, if bleeding could cut short or diminish the duration of a pneumonia, it might have been expected in this case. Yet so far from proving beneficial, they appear to me to have assisted in prolonging the case, and preventing resolution and recovery. For although the critical diaphoresis, and discharge of lithates by urine, occurred on the fourteenth day, the subsequent weak- ness was considerable. On his admission into the house, the 8th day of the disease, the chlorides were observed to be absent from the urine. This fluid was tested daily for these salts, which returned in small quantity on the twelfth, and were abundant on the thirteenth day of the disease. If, as we shall subsequently see, it is probable their reappearance indicates a cessation of fresh exudation, then it was observable that on the day following, excretion of the morbid products commenced by the skin and kidneys. The interval between the return of chlorides to the urine and the critical period, varies considerably in different cases; but the careful estimate of these facts in future will, I think, furnish us with valuable hints as to the vital power of the exudation. If, for instance, it should ultimately be shown that the return of chlorides indicates stoppage of exudation, and the presence of lithates or other critical discharge, the commencement of excretion of the exudation, then we shall possess evidence not previously discovered, as to when the pathological lesion is checked, and when the reparative changes in the economy commence. Another fact, which excited considerable attention in this case, was the characteristic cracked-pot sound under the right clavicle. The physical, signs sufficiently proved that the pneumonic condensation com- menced at the base of the lung, and proceeded upwards, where, poste- 684 DISEASES OF THE RESPIRATORY SYSTEM. riorly and anteriorly, a considerable amount of air was retained in the air vesicles, so that percussion was never dull, although crepitation aud increased vocal resonance existed. This presence of condensed lung, covered with or surrounded by air, or of a cavity containing air, sur- rounded by condensed tissue, seems to constitute the condition under which this peculiar noise is elicited when the mouth is open. Hence the occurrence of the cracked-pot sound (bruit de pot fete) is common in pneumonia, and in a variety of diseases which present similar physical conditions.* Case CLLf—Double Pneumonia—Treatment by Mercury, which caused Profuse Salivation before Admission—Prolonged Recovery. History.—Robert Jude, set. 36, a bricklayer—admitted 10th December, 1855. On the 1st instant, while engaged building bricks round a boiler, the weather being very cold and windy, he suddenly felt a pain in the chest, deep-seated, half way between the ensiform cartilage and umbilicus. The pain rapidly grew worse, and caused nausea, but he could not vomit. He immediately went home, took some gruel, and went to bed. On the 4th, a medical man gave him some pills, one of which he took every third hour. On the 6th his teeth were loose, the gums very tender, and the tongue swollen to twice its natural size, so that he could not spit out the excessive amount of saliva that was secreted, and which consequently flowed from his mouth. He also had pain in the loins. Symptoms on Admission.—On admission, the excessive salivation has much di- minished, but there is still tenderness and redness of the gums, with considerable dis- charge from the mouth. The breath foetid, the tongue covered with a dense, dirty white coating. The bowels, while taking the pills, were open from six to seven times a day; they are now regular. His diet has been confined to farinaceous articles. On percussing the chest anteriorly, it is everywhere resonant, but posteriorly it is dull on both sides, most so on left side. On auscultation anteriorly nothing abnormal, but pos- teriorly respiratory murmurs are harsh and shrill, with occasional sibilation. At the base on right side, there is crepitation on inspiration; on the left side respiration is tubular. Vocal resonance equal superiorly and anteriorly, but posteriorly everywhere increased, on the left side amounting to bronchophony. Pulse, 96, weak; heart sounds normal; skin hot, moderately dry, but there has been profuse perspiration ; there is dull pain in lumbar regions; urine opaque from the existence of a reddish cloud; sp. gr. 1024, not coagulable, but clears on the addition of heat; chlorides diminished in quantity. R Sp. JEther. Nit. 3 iij ; Potass. Acet. 3 ij; Aquam ad §yj. M. One table-spoonful to be taken every four hours. R Liquor. Soace Chlor § j; Sp. Vini Gallic. § ss ; Infus. Rosar. c. ad 3* vj. M. Ft. gargarisma. Progress of the Case.—December 11th.—Crepitation more diffused over right back. On left side respirations still dry and harsh. Chlorides absent from urine. Dec. 12th.—Crepitation now audible over left back. Lithates in urine more abundant. Discharge of saliva still copious, but greatly diminished in amount. Pulse 80, weak. Habeat Vini § iij per diem. Dec 13th.—Chlorides in urine again perceptible. Dec. 14th.—Chlorides in urine abundant. Crepitation posteriorly diminishing, sputum still copious, frothy, and somewhat gelatinous. Breath continues to give off the mercurial foetor. Dec. 15th.—Last night had copious diaphoresis, followed by great relief in his breathing. Still a few crepitations posteriorly, increased vocal resonance, more marked on left than on right side. Urates very abundant in urine. From this time he gradually improved. On the 21st all moist rale had disappeared, but respiratory murmurs harsh posteriorly, and vocal resonance still increased. Dec. 26th.—Still a coppery taste in the mouth. Yesterday felt hungry for the first time, and was ordered an egg for breakfast and steak for dinner. From this time he rapidly recovered, and he was dismissed January 2, 1856. Commentary.—In this decided case of pneumonia, with absence of chlorides from the urine, we had an opportunity of observing the effects * See the Author's clinical investigation into the diagnostic value of the cracked pot sound—Edin. Med. Journal, vol. i., p. 789. 1856. t Reported by Mr. John Glen, Clinical Clerk. PNEUMONIA. 685 of mercurial salivation on the progress of the disease. If it be con- trasted with many other cases of the same kind previously recorded, it will be seen that the disease itself was in no way shortened by the exhibition of mercury. Resolution commenced on the fourteenth, but was not completed till the twenty-first day. On the other hand, the unpleasant effects produced by the mercury, the severe swelling of the tongue, soreness of the gums and profuse salivation, must not only be regarded as so many increased evils aud unnecessary symptoms super- added to the original disease, but as being the cause of prolonging the convalescence. For although the leading physical signs had disappeared on the twenty-first day, he could not eat until the twenty-sixth day, in consequence of the coppery taste in his mouth. But as soon as nutri- ents could be taken, he recovered rapidly. No fact could better demon- strate the utter uselessness of the drug, and its occasional mischievous effects. Case CLIL*—Pneumonia—ushered in by Violent Vomiting and Gastric Pain—Recovery in five days. History.—Edward Nugent, set. 28, a waiter—admitted November 8th, 1858. Has always enjoyed good health until about three weeks ago, when he went to Liver- pool from Glasgow by water, and suffered very severely from sea sickness. Three days afterwards, on the return passage, he was again very sick, and for a few days after felt soreness in the epigastric region. He then became quite well until Monday the 8th, at 1 p.m., when, whilst cleaning plate, and about ten minutes after eating a hearty dinner, he was suddenly seized with severe pain in the epigastrium, cold sweats, vertigo, desire to vomit, but inability to do so. He was immediately con- veyed to the Infirmary. Symptoms on Admission.—The patient was pale and livid, almost pulseless, and complained of sickness, cold, profuse clammy perspiration, and great pain in epigastri- um, increased on pressure. Shortly after admission he vomited what he had taken at dinner, but was not relieved; warm bottles were applied to his feet, and hot fomenta- tions to the painful part. His suffering continued ; at 4 p.m. six leeches were applied to the epigastrium, and 3 ss of Sol. of Morphia administered. These remedies gave some relief, and he remained in comparative ease till about 10 p.m., when some Magn. Sulph. was given, as the bowels had been costive for some days previously. Progress of the Case.—November 9th.—He had no sleep during the night, and his symptoms have remained stationary. He has had three or four dark colored stools. Early in the morning he was ordered for the vomiting R Creasoti gtt. ij ; Sol. Mur. Morph. 3 ss ; ft. haust.; also a table-spoonful of Port wine every hour. At the visit (noon) his symptoms had in no way abated, and he was ordered to continue the wine ; to take beef tea in small quantities ; and a tea-spoonful of the following mixture every hour until the pain decreased:—R Sol. Mur. Morph. 3 ij ; Sp. JEth. Sulph. 3 vj ; Ft. mist. The mixture caused great relief, and in the afternoon he was able to bear further examination. The cardiac sounds were indistinct; pulse 58, extremely feeble and intermitting. Respiration labored, and the pain in epigastrium increased during inspiration. There was slight harshness of inspiration, and increased vocal resonance under both clavicles. He had great pain at the back of his head, and some giddiness ; tongue dry and furred ; no appetite; great thirst; no perceptible swell- ing in epigastrium ; abdomen tender and hot; urine natural in color and quantity, but only a slight trace of chlorides. In the evening he was better, the pain had greatly subsided, and there was less sickness ; he was able to retain some small quan- tities of beef tea. Slight dulness, increase of vocal resonance, and crepitation, were detected at the base of the left lung posteriorly. Nov. 10th.—He passed a tolerably good night, and had some sleep ; the epigastric pain and sickness still further diminished. Pulse 98, weak. The physical signs observed in left lung last evening were not audible at visit, but were again heard in the evening. Ordered to discon- tinue the mixture, and to continue the wine and beef tea in small quantities. Nov. * Reported by Mr. Arthur Garrington, Clinical Clerk. 686 DISEASES OF THE RESPIRATORY SYSTEM. 11th.—He passed a good night; he still has slight sickness and tenderness over epigastrium. He complains of pain in the left breast, increased during inspiration; he has some shortness of breath, troublesome cough, and a greyish, tenacious sputum containing a few rusty-colored masses. Marked duiness, with increased vocal reson- ance, and clear crepitation, audible over lower third of left side posteriorly. Pulse 88, tolerably full; tongue loaded. The patient says he has had rigors every day since ad- mission, and yesterday was so cold that he had warm bottles applied to his feet. On examination of the urine, the chlorides were still diminished, and there was a deposit of triple phosphates. Nov. 12th.—Now sleeps well. His appetite is much improved. The epigastric pain and tenderness and the sickness have disappeared. Pulse 90, full and regular. Crepitation very fine; vocal resonance still increased. Cough not so bad, no rusty masses in the sputum. Nov. 13th.—The crepitation has disappeared; there is some harshness of inspiration. Sputum muco-purulent. Chlorides abundant in the urine. His bowels being confined, he was ordered an enema of warm water. Nov. 15th.—Respiration quite natural. He says he only feels a little weak, but is otherwise so well that he insists on being discharged. Commentary.—In this case of severe gastric irritation, pneumonia came on in the Infirmary—was well characterized by all the symptoms and physical signs of the disease, was limited to the posterior third of the left lung, occurred in a healthy young man, and was treated by stimulants and nutrients from the beginning. The result was recovery on the fifth day and discharge from the hospital at his own request quite well on the seventh day. It is the most rapid recovery from decided pneumonia that has ever fallen under my notice. The fact3 of this case are also entirely opposed to the notions of those who consider that inflammation is in some way connected with a sthenic or excited state of the system. The man was in perfect health when seized with the gastric spasms, and was by them reduced to a pulseless and exceedingly prostrated state, with cold clammy sweats. It was in this weakened condition that the pneumonia arose, and its limited extent and short course I ascribe to the stimulants, nutrients, and quietude with which it was treated from the first. On the Diagnostic Value of the Absence of Chlorides from the Urine in Pneumonia. Simon and Redtenbacher first stated that chloride of sodium, a salt always present in healthy urine, was absent from that fluid during the onward progress of pneumonia, and returned to it when absorption of the exudation was about to commence. This statement was confirmed hy Dr. Beale of London, who, in the 35th vol. of the Transactions of the Medico-Chirurgical Society of London, furthered our knowledge regarding it by additional valuable researches. My attention was directed to this remarkable fact during the Session 1853-54, by Dr. Robert Cartwright, a gentleman attending the Clinical Wards of the Infirmary, who informed me that he had seen it occasionally of great service in a diagnostic point of view, in the clinical wards of Professor Oppolzer at Vienna. It so happened that a man, John M'Donald, set. 25, had just been admitted, laboring under well-marked simple pneumonia at the apex of the right lung. He was a laborer, who had enjoyed perfect health until two days before admission, when, on being exposed to Avet and cold, working at drains, he was seized with shivering, followed by fever and the usual symptoms and signs of pneumonia. On adding a drop of nitric acid to some of his urine in a test tube, and then dropping into it a little of the PNEUMONIA. 687 solution of the nitrate of silver, the fluid remained clear, although so great is the delicacy of this test, that a white cloudy precipitate is at once formed, if a very minute quantity of the chloride of sodium be present. It was on the fourth day of the disease that the observation was first made, and the chlorides remained absent during the fifth and sixth days, during which period the disease extended from above downwards, until it occupied the upper two-thirds of the right lung. On the seventh day a slight haze was observed in the urine, indicating that the salt was re- turning to the fluid, and the man expressed himself as being much better. On this day there was great dulness on percussion, all crepitation had ceased, the breathing was tubular with bronchophony. On the eighth day, slight returning crepitation was audible, the dulness had diminished, but the urine, owing to some accident before the visit, had been thrown away. On the ninth day, however, the chlorides were abundant in that fluid, together with lithates; loud crepitation was now universal through- out the lung, and the dulness had nearly disappeared. From this time the man made a rapid recovery, never having been bled, and was dis- charged quite well on the sixteenth day. I now requested Mr. Seymour, one of the clinical clerks, to test the urine of all the patients in the ward, and others who might subsequently be admitted, which he did, and thus collected a large number of observa- tions, the results of which I shall allude to immediately. In the mean time another case entered, which seemed to point out the value of this test in a diagnostic point of view. It was that of a man, Donaldson, set. 26, laboring under typhus fever, in whom the disease ran its usual course to the tenth day, when chlorides were demonstrated in it. On the eleventh day, however, pulmonary symptoms came on, and the chlorides were entirely absent from the urine. This led me to make, with the clinical class, a careful examination of the chest, when all the signs of pneumonia were detected in the lower half of the right lung. On the fourteenth day the chlorides reappeared, the pneumonic signs diminished, and the fever ceased with a critical sweat. A third case was even more satisfactory in proving the moment of commencing and departing pneumonia by testing the urine for chloride of sodium. A man called David Murray, aet. 43, entered with pneumonia of the lower two-thirds of the right lung. No consistent account could be obtained from him as to when the disease commenced, and it was im- possible, therefore, to determine whether the coarse crepitation which was audible over the inflamed lung was the advancing or returning crepita- tion ; but the chlorides were absent from the urine, which indicated that the disease was advancing. The following day complete consolidation had occurred, with dry tubular breathing and absence of crepitation, and a minute quantity of the chlorides was found in the urine. The patient, however, instead of getting better, showed no improvement, and the next day the chlorides had again disappeared, indicating extension of the pneumonia. On the evening of this day he was seized with acute meningitis, of which he died. On dissection, in addition to universal cerebral meningitis, the whole of the right lung presented the usual characters of grey hepatization. (See Case IV.) It will be observed in all the preceding cases, thirteen in number, 688 DISEASES OF THE RESPIRATORY SYSTEM. that with the exception of Case CXXIX., the absence or decided diminution of chlorides marked precisely the onward march of the pneumonia, whilst their presence indicated its cessation, and was generally accompanied by the returning crepitation and commencing absorption of the exudation. It still remains to be determined whether the absence of the salts is a cause or a result of exudation into the lungs—whether the interference to the respiratory functions, by diminishing the amount of oxygen absorbed, gives rise to these chemical changes in the blood which react on the urinary secretion. If so, what is the nature of these changes ? Indeed, a crowd of questions will be suggested to the mind of the physiologist from the establishment of the remarkable clinical fact of which we are now speaking. That such is an important diagnostic sign I have no doubt, and it was singularly well tested in the following case, in which there were many signs and symptoms of pneumonia, complicated with heart disease. The question on admission was whether, with heart disease and bronchitis, pneumonia might not be conjoined, and I was assisted in answering in the negative by the abundance of chlorides which the urine contained. Case CLIII.*—Bronchitis and Pulmonary Congestion, from Morbus Cordis, resembling Pneumonia, but no absence of Chlorides in the Urine. History.—John Dickson, set. 44, pensioner—admitted July 21st, 1854. Says that on the evening of the 19th he was seized with chilliness, followed by sweating, heat of skin, thirst, impaired appetite and expectoration of a frothy fluid, resembling liquorice juice. He has for some time felt an uneasy sensation in the epigastrium, which, since his recent illness, has amounted to pain. Yesterday he experienced great dyspnoea and anxiety, symptoms which have continued until now. Symptoms on Admission.—On admission there is excessive dyspncea, with expec- toration of a tenacious sputum, of a reddish-brown color. On percussion, there is no comparative dulness, but posteriorly the resonance is impaired on both sides. On aus- cultation anteriorly, the expectoration is everywhere much prolonged, and posteriorly there is considerable crepitation with bronchophony. Pulse 92, of good strength. The heart's sounds are entirely masked by the prolonged wheezing expiration and agi- tation of the chest. He cannot lie on his back or left side, is easily agitated, frequently experiences palpitations, and cannot sleep. Abundant chlorides in the urine. Other functions normal. R Sp. JEther. Sulph. 3ss: Aq. Cassice\^iv. One table-spoonful to be taken in water occasionally. To have one-quarter of a grain of Antim. Tart, in solution every two hours. Progress of the Case.—July 25th.—Since last report the dyspncea has diminish- ed, the crepitation posteriorly continues, but the wheezing anteriorly is less. Still gelatinous sputum, specked with rusty-colored blood. The apex of the heart cannot be felt, but a double blowing murmur is now recognizable, accompanying both the first and second sounds—the systolic, loudest at the apex, and the diastolic, loudest at the base. Omit the Antimony. July 31st.—The pulmonary symptoms and signs have now greatly subsided, whilst the cardiac lesion has become more distinct. For this latter he remained in the house until the commencement of November, when he was dismissed greatly relieved. Mr. Seymour tested with great care, and at repeated times, the urine of upwards of fifty other cases in the wards, embracing a great variety of disease. He found the chlorides absent in one case of phthisis, with intercurrent pneumonia, but in no other. They were also absent in one case of peritonitis, and in all the cases of small-pox. Further investiga- tion will probably discover these salts to be absent in other diseases * Reported by Mr. Almeric Seymour, Clinical Clerk. PNEUMONIA. 689 which, although it may diminish the importance of the sign as distinctive of pneumonia, leaves unaffected its value as pointing out the onward progress of that disease. In one or two cases of pneumonia, in which the disease was pro- gressing, traces of chlorides were seen in the urine. This was discovered by Mr. Seymour (clinical clerk) to depend on the adulteration of the nitric acid, which, for testing urine, must be pure. The nitric should be tested according to the directions of the Edinburgh Pharmacopoeia for hydro- chloric acid, with which it is very apt to be mingled. It is of import- ance that pure nitric acid be added to the urine in the first instance, otherwise the nitrate of silver is very apt to throw down phosphates, which, however, may be distinguished from chlorides by being dissolved in an excess of nitric acid, which does not affect the latter salts. What is very remarkable with regard to the absence of chloride of sodium from the urine, is that it appears in the sputum of pneumonic persons, and as it returns to the urine, it disappears from the sputum. I have not myself, however, made many careful observations on the chemical reactions of the sputum in this disease, but propose doing so, in the hope that it will throw further light on its diagnosis and pathology. The Pathology of Acute Pneumonia. The pathology of pneumonia is comprised in what has been formerly said on exudation, p. 166, and more especially p. 173, the lesion con- sisting of liquor sanguinis poured into the air vesicles, minute bronchial tubes, and parenchyma of the lung. It maybe well, however, to dwell a moment on the fact that the exudative process may be very limited, indeed confined to a few vesicles, and the minute bronchial tubes connected with them. This is vesicular pneumonia. We know it may be confined to a lobule or occupy an entire lobe, constituting the so-called lobular and lobar pneumonia. In either case the essential phenomenon of in- flammation, that is, exudation, has occurred, distinguishable on careful examination of the pulmonary tissue, by the blocking up of air vesicles in the form of minute granulations. Occasionally the vesicular exudation may be felt on handling the lung in the form of minute indurations, varying in size from a millet seed to that of a pea—often red, but occasionally yellow, and in the latter case very liable to be mistaken for tubercles. Such small indurations, however, at length soften, and arc converted into pus, like the lobar and lobular forms of pneumonia. Microscopic examination of the pulmonary tissues shows us that, in the first instance, the air vesicles, the minute bronchi, and the areolar tissue, are infiltrated with a molecular and granular exudation, which often forms a complete cast or mould of the vesicles and bronchi, easily separated mechanically by washing and pressure. Not unfrequently, 'as shown by Remak, these moulds are expectorated entire, and may be dis- engaged from the gelatinous matter with which they are associated, by throwing the contents of the spit-box into water, and teazing out the branched filaments. These, when magnified, present a fibrous exudation, in which are embedded commencing pus corpuscles, with a greater or less number of epithelial cells (Fig. 80). Such portions of exudation as 44 GOO DISEASES OF THE RESPIRATORY SYSTEM. remain in the lung are transformed into pus in the usual manner (Fig. 154, p. 174), become ultimately disintegrated and absorbed into the blood, where they are chemically changed, and at length excreted from the system, principally by the kidneys (p. 174). If, from the extent of the disease, or weakness of the patient, this process is checked, the patient may die, either from inability to excrete the effete matter in the blood, or from interruption to the respiratory functions. If the exudation be limited in extent, or have been poured out slowly from the commence- ment, it may become what is called chronic. Under such circumstances, the epithelial and pus corpuscles of the pulmonary tissues may undergo . the fatty degeneration, and numerous compound granule cells be the re- sult. If blood should have been extravasated, mingled with the other formations described, there will be often found red crystals of haematine, blood corpuscles surrounded by an albuminous layer, and presenting the numerous transformations which they are known to undergo after ex- travasation (Fig. 411, p. 418). Dr. Todd * observes, " When a patient suffers from pneumonia, the tendency is for the lung to become solid, then for pus to be generated, and at last for the pus-infiltrated lung-structure to be broken down and dissolved. Such are the changes when matters take an unfavorable course. On the other hand, recovery takes place, either through the non-completion of the solidifying process, or by the rapid removal, either through absorption, or a process of solution and discharge, of the new material, which had made the lung solid." Now I have directed especial attention to the method in which the exudation is absorbed, and have frequently examined lungs after death in the stage of red hepatization, where death had occurred from cerebral hemorrhage or other disease. In some lungs there has been a pneumonia in all its stages, incipient in some places, solidified and red in others, grey and purulent in a third. In all these places, a gradation in pus formation has been observable. In the most solid hepatization, young pus cells may be observed some- where beginning to form, so that I am convinced that the exudation is always broken down through the agency of purulent formation—in short, that this is the normal process. I have never seen any evidence that a coagulated exudation is simply disintegrated and absorbed without the development of pus cells, and I conceive that all analogy, as well as direct observation, is opposed to the supposition. It follows that, so far from the formation of pus being the evidence of an unfavorable course of the disease, it is the normal and necessary transformation of the solid exudation, whereby it is broken up and caused to be absorbed. (See Fig. 154, p. 174.) This view, based upon numerous careful histological examinations of pneumonic lungs, and easily capable of demonstration in any recent specimen of the disease, as well as by many preparations in my collection, shocks the notions of certain pathologists of the French school. M. Grisolle recently observes of it:—" I cannot accept a doctrine that is not justified by any direct proof, from which the clinical sense in a manner revolts, and which is manifestly contrary to what has been taught and is still taught every day by the simplest observation of physicians * Beale's Archives of Medicine, No. 1, p. 2. PNEUMONIA. 691 throughout the world." * If, before writing such a criticism, M. Grisolle had investigated the subject in the only way in which it can be investi- gated—that is, with the microscope—he would have seen in red hepa- tization pus corpuscles in all stages of formation, and thus convinced himself of a truth which, so far from revolting the clinical sense, presents to it new and important arguments for a more successful practice, as will be subsequently shown. The microscope has proved that many so-called purulent fluids are not purulent at all, whereas it distinctly demonstrates that the disintegration, softening, and liquefaction of the plastic exudation in pneumonia—processes admitted by M. Grisolle—are in truth the result of a vital growth of pus-cells; by favoring which we can cause recovery in our patients, and by diminishing or interfering with which we increase the mortality among them. The direct proof that M. Grisolle requires he may himself obtain by making a few sections of any pneumonic lung with a Valentin's knife, and carefully examining them first under a magnifying power of 25, and then of 250 diameters linear, when he will see appearances similar to those now figured, and recognise— Fig. 452. Fig. 453. 1st, Molecular exudation in the air-vesicles ; 2d, Passage of this by molecular coalescence into pus-cells; and, 3d, Formation and subsequent degeneration of such cells. (See Molecular and Cell Theories of Organi- zation, p. 115. See also Fig. 154.) Indeed, so constant is the formation of pus in pneumonia, and so clearly can it be seen to form by mole- * Traite de la Pneumonie, 2me edit., 1864, p. 53. Fig. 452. Vertical section through the outer portion of a lung affected with pleuro-pneumonia. Externally, the exudation on the surface has formed a thick layer of molecular fibres, and shows villi, which, on becoming vascular, absorb the serous fluid. The lower half of the figure shows the air vesicles of the lung blocked up with the coagulated molecular exudation. 25 diam. Fig. 453. Two moulds of coagulated exudation from air vesicles in red hepatization of the lung, a, Molecular exudation, aggregating into small masses to form pus cor- puscles. 6, A neighboring mass, in which the exudation has proceeded further in de- velopment, and is forming pus-cells. 250 diam. • 692 DISEASES OF THE RESPIRATORY SYSTEM. cular aggregation, independently of pre-existing cells, as in itself to carry with it a complete refutation of Virchow's doctrine, '' omnis cellula e cellula." The exudation having been transformed into pus-cells, these, after a time, become fatty, break down, disintegrate, and liquefy, and are absorbed into the blood, whence they are excreted by the emunctories, but more especially by the kidneys, in the form of urates, as previously explained. (See p. 174.) Treatment of Acute Pneumonia. In the first place, let us more particularly examine the effects of the four kinds of treatment recommended in Pneumonia—viz., by bleeding, by tartar emetic, by an antiphlogistic diet, and what may be called a mixture of these treatments. Results of the Treatment of Pneumonia by large Bleedings.—It appears from the published statistics of the Royal Infirmary of Edin- burgh, that upwards of one-third of all the patients affected with pneu- monia died who entered during a period of ten years, when bleeding was universally practised. No doubt it cannot be pretended that per- fect accuracy as to diagnosis was attained in all the cases. It is certain also that numerous complications and the debilitated constitutions so frequently met with in the practice of a large hospital, served to swell the mortality. It is remarkable, however, that this proportion of deaths to recoveries is nearly the same as has occurred in the Infirmary since the commencement of the present century, as well as what resulted in the cases so carefully observed by M. Louis, in the hospital of La Chari- te, at Paris. TABLE, showing the Number of Patients affected with Pneumonia treated in the Eoyal Infirmary of Edinburgh, and the results, from July 1st, 1839, to October, 1st. 1849. Total No. of Patients entering the Years. No. ad-mitted. Cured. Re-lieved. Died. Statistician. Imirmary. 7,969* 1st July 1839 to 1st Oct. 1841 139 85 5 49 Dr. John Reid. 3,537 1st Oct. 1841 ' 1842 42 23 3 16 >Dr. T. Pea- 2,760 " 1842 ' 1843 41 26 0 15 \ cock. 7,204* " 1843 ' 1844 31 16 4 11 ] 3,252 " 1844 ' 1845 50 33 4 13 1 Dr. Hugbes 3,638 " 1845 ' 1846 61 40 6 15 7,435* " 1846 ' 1847 93 47 5 41 7,446* " 1847 1848 103 52 6 45 J X, ,. 3,724t " 1848 1849 88 66 5 17 Mr. M'Dougall. 46,965 648 388 38 222 * At these periods there were great epidemics of fever. | At this period considerable changes took place among the medical staff of the Infirmary. PNEUMONIA. 693 My former clerk, Dr. Thorburn, was kind enough, at my request, to go over 208 case-books of the Infirmary, dated between the years 1812 and 1837, and belonging to twelve physicians, all of whom practised an antiphlogistic treatment. He found that of 103 cases of pneumonia, 55 were cured, 41 died, and 7 were relieved—that is, 1 death in 2£ cases. Dr. Thorburn then carefully read over these 103 cases, and rejected all those that were incomplete, or which presented no evidence of having been pneumonia. The remainder were tabulated, and it may safely be said that they were all cases of pneumonia, or of acute inflammations of the chest closely allied to that disease, and the result was :—Number of cases, 50 ; died, 19 ; cured or relieved, 31—that is, more than 1 death in 3 cases. The total number of cases, recorded by M. Louis, was 107.* Of these 32 died, or 1 in 3i. In 78 of those cases, which occurred at La Charite, bleeding was performed from the first to the ninth day, and the deaths were 28, or 1 in 3|. The duration of the disease in the cases which recovered was 15i days. Of the remaining 29 cases, which occurred at La Pitie, the bleeding was performed earlier, that is, during the first 4 days, and of these only 4 died, that is 1 in 7 J. The dura- tion of the disease, however, in the cases that recovered, was 18i days. This diminished mortality, but greater length of recovery, M. Louis at- tributes to the bleedings not having been so large, and the greater amount of tartar emetic employed. Hence, the proposition he sought to estab- lish, that although bleeding has a very limited influence on pneumonia, it should be practised early. With regard to M. Louis's results, it should be remembered that all these patients enjoyed excellent health when they were attacked, that the cases were uncomplicated, and that the duration of the disease was estimated from the occurrence of febrile symptoms, up to the time when light food could be taken, which was generally three days after the fever had ceased. M. Grisolle f advocated more moderate bleedings than those so fre- quently had recourse to, his conscience preventing the abandonment of venesection altogether (p. 561). He analyses the 75 cases of Bouillaud, pointing out that only 49 were treated by the coup sur coup mode of bleeding, of which 6 died, or 1 in 8 cases, a favorable result, which he attributes to the youth of the patients treated. Of his own cases, one group of 50 cases were bled only in the first stage of the disease ; of these 5 died, or 1 in 10. Those cases that died were bled most, each losing about 4 lb. 4 oz. of blood in successive bleedings. All the cases in this group were uncomplicated, and of the average age of 40 years. Of the 45 who recovered, convalescence commenced on the 10th day, and they resumed their occupations on the 21st day, as an average. Of 182 cases that were bled in the second stage, 32 died, or more than 1 in 6. Here also those who died were bled most—the bleedings varying in amount from 8 or 12 oz. to 8 lbs. The average quantity lost was 3 lbs. All the cases in this group were uncomplicated, and of the average age of 35 years. Of the 150 cases that recovered, convalescence commenced on the 17th day, and they resumed their occupations on the 22d day—as an average. He admits that the pneumonia can never be jugulated by * Recherches sur les effets de la Saignee. Paris, 1835. f Traite pratique de la Pneumonie. Paris, 1841. 694 DISEASES OF THE RESPIRATORY SYSTEM. bleeding. Of the whole 232 cases, 37 died, that is, about 1 in 6i, as the general result of M. Grisolle's hospital practice, a mortality only one-half that of M. Louis's cases, although the circumstances under which they occurred were the same, with the exception of not being so heroically treated. Laennec also, who only bled moderately at the com- mencement of the disease, regarded the mortality to be 1 death in 6 or 8 cases.* In 1864 M. Grisolle published another edition of his work, in which these old statistics are repeated without any change whatever, and this notwithstanding his acquaintance with the author's researches, and the immense improvements which have taken place in the art and science of medicine during the long interval of 23 years. What seems very sur- prising is, that he wishes to have it believed that his antiphlogistic treat- ment, with a mortality of 1 in 6 cases, is still the best. Dietl treated 85 cases by large bleedings, of whom 17 died, that is, 1 in 5. Dr. Glen, my former resident clerk, was so good as to tabulate for me all the cases of pneumonia given in the army returns, and reported by Colonel Tulloch.f These returns give us no information as to the mode in which the diagnosis was determined, or what was the treatment. The favorable mortality of 1 death in 13 cases, which, according to Dr. Glen, is the general result, is supposed to result from the bleedings having been performed early, and in young vigorous subjects. Von Wahl treated, in St. Petersburg, by bleeding and antiphlogistics, 354 cases, of whom 84 died, or 1 in 4f cases.! Treatment by large doses of Tartar Emetic.—Rasori, § in the great hospital of Milan, treated 648 cases by large doses of tartar emetic, of which 555 were cured, and 143 died, that is, 1 in 4i. In publishing this statement, Rasori gives the result as one more favorable than the practice of blood-letting, which of course he would not have done unless the latter treatment was then well known to have been attended with a greater mortality than that by tartar emetic, or 1 death in 4J cases. M. Grisolle treated 154 cases with large doses of tartar emetic, of which 29 died, that is, 1 in 5^, and Dietl treated 106 cases, of which 22 died, that is, a little more than 1 in 5. Treatment by Diet.—This treatment essentially consists in allowing the disease to go through its natural course. During the stage of fever diet is light, or withheld altogether, and cold water allowed for drink; subsequently better diet is allowed, and occasionally wine, according to the nature of the symptoms. Sometimes a dietetic is converted into an expectant treatment, when remedies are given to meet occasional symp- toms, as in the practice of Skoda, in the Charity Hospital of Vienna. * Forbes' Translation. Fourth Edition, p. 237. j Government Statistical Reports on Mortality among the Troops. 1853. i Petersburg Med. Zeit., i. 6. 1861. §From an Analysis of Rasori's Practice—Annales de Therapeutique, Janvier PNEUMONIA. 695 An account of this has been given to us by Dr. George Balfour, who found from the books of the hospital, that during a period of three- years and five months, commencing 1843, 392 patients were treated, of whom 54 died, or 1 in 71. Occasionally opium was given in small doses if there was much pain. Venesection was also practised early if there was much dyspncea, and emetics given if the expectoration con- sisted of tough mucus. ^ Dr. G. Balfour has also given some statistics of the Homoeopathic Hospital of Vienna, accompanied, however, with statements which ren- der it doubtful whether every case that applied was admitted, and con- sequently not fairly comparable with other hospital statistics. There can be no doubt, however, that many severe cases of pneumonia recovered under a system of treatment, which, it appears to me, most medical men must consider to be essentially a dietetic one. Dr. Dietl published, in 1848, an account of 189 cases treated by diet only, of which 14 died, that is, 1 in 13 J. The following is his table of 380 cases, exhibiting the result of the three kinds of treatment:— Vene-section. 68 ...... Tartar Emetic. ........ 84......... Diet. ,...... 175 Died 11 ....... ........ 22 ........ ....... 14 85 ....... ........ 106 ........ ....... 189 ___ 20.4....... ........ 20.7....... ....... 7.4 ...... 1 in 13* It was further observable that of the 85 cases treated by blood-letting, 7 of the fatal cases were uncomplicated; whilst of the 189 cases treated by diet, not one of the deaths was an uncomplicated one. In 1852 he gave the result of 750 cases, treated dietetically, of which 69 died, or one in 10.9. Mixed treatment.—In recent times cases of pneumonia have been treated after a mixed fashion, according to the nature of the symptoms, but with no very marked beneficial result. As examples of this system, I may refer to the results given by Huss, Bamberger, and Flint. The most important memoir recently published is that of Professor Huss of Stockholm,* who employed bleeding and heroic remedies in the early stage, and in the later ones antimony, mercury, and various reme- dies—among the rest, turpentine, morphia, and quinine. The number of cases given is 2616, of which 281 died; that is, 1 in 9£ cases. The un- complicated cases were 1657, of whom 96 died, or 1 in 17 cases. The complicated cases were 959, of whom 185 died, or 1 in 5 cases. The treatment employed was adapted, as it was thought, to the emergencies of the case, and may be called a modified antiphlogistic practice, many cases not having been bled at all. Its superiority over the rigid system, and even over that of Grisolle, therefore, is marked. Dr. Bambergerf treated 186 cases without general blood-letting. * Die Behandlung der Lungen-entzundung, etc. Leipsig, 1861. f Wiener Wochenschrift, No. 50, 1857; and Canstatto Jahnnberricht, 1858, iii. p. 284. 696 DISEASES OF THE RESPIRATORY SYSTEM. Only a few leeches and fomentations were applied in some cases, and inf. digitalis given internally. Occasionally, also, expectorants, emetics and other remedies were employed. Nothing is said of diet or wine. Of these cases, 21 died, or 1 in 9. Number of complicated cases not stated. Dr. Flint has given the result of 133 cases he treated, of whom 35 died—more than 1 in 4. Among the uncomplicated cases were 19 deaths, and among the complicated 16—a strange result. The treat- ments varied according to the case; 12 were bled.* The Author's Treatment by Restoratives, directed to further the natural progress of the disease, and supporting the vital strength.—A study of the pathology of the disease, which I have previously explained many years ago, forced upon ray mind the conviction that blood-letting and antiphlogistics must be injurious. Pus-cells must be regarded as living growths, and as such require an excess of blood, good nutrition, and exalted vital force to hurry on their development and carry them success- fully through the natural stages of their existence. If the resolution of a pneumonia simply consisted of a retrograde process, of a so-called necrosis of the exudation, a previous antiphlogistic practice, by favoring it, might be expected to relieve the lung rapidly and cure the disease. But my conviction that such removal was dependent upon vital pro- cesses of growth, led me to an opposite treatment, viz., never to attempt cutting the disease short, or to weaken the pulse and vital powers, but, on the contrary, to further the necessary changes which the exudation must undergo in order to be fully excreted from the economy. To this end, during the period of febrile excitement I content myself with giv- ing salines in small doses, with a view of diminishing the viscosity of the blood. At the commencement of the treatment I order as much beef-tea as can be taken, and, as soon as the pulse becomes soft, nutri- ents, and from 4 to 8 oz. of wine daily. As the period of crisis ap- proaches I give a diuretic, consisting of half a drachm of nitric ether, and sometimes ten minims of colchicum wine, three times daily, to favor excretion of urates. But if crisis occurs by sweat or stool, I take care not to check it in any way. The object of this practice has been greatly misunderstood, and by none more so than by M. Grisolle, who calls it an expectant treatment. It seems to me to differ entirely from it in the care which is taken to nourish the weakened frame from the beginning, and thus, according to the pathological views formerly explained, assist the vital powers to change the coagulated exudation, first into a new morbid growth (pus), and then into a fluid capable of absorption. I cannot call it a dietetic treat- ment, because this term has been applied on the Continent to with- holding diet rather than giving it—the " diete absolue " of the French meaning starvation—a fact which explains the fatal result of this practice, and especially the ill success of M. Grisolle, when he tried expectancy—or, as he understands by that practice, withholding all nourishment—while at the same time the bowels are acted on by injections and castor-oil (p. 559, 2d edit.) My pathology, in his * American Journal of Medical Sciences, 1861. PNEUMONIA. 097 opinion, appears strange, and useless to refer to (Idem, p. 568); but as it has led me to cure every case of single and double uncomplicated pneumonia, whereas among M. Grisolle's cases there is a mortality of one in every six, I may be permitted to think my theory better founded on observation, while my practice supports its correctness. In order, however, that there may be no farther misapprehension as to the facts which demonstrate the success of the restorative practice fol- lowed in my clinical wards, I give, in a tabular form, all the cases which have entered since the year 1848. The following Table includes all the cases of acute pneumonia which have been admitted into the clinical wards of the Royal Infirmary under my care since the 1st of October 1848 to the 31st of January 1865. During this period my term of service was at first four months in the year, and then, on alternate years, six months and three months. I find that, altogether, I have treated cases in the wards for 75 months, or a com- puted period of 64; years. The Table presents the leading facts presented by the cases, so as to enable the reader to judge of the effects of the treat- ment employed. The columns indicate—1st, The number of the case ; 2d, The name of the patient—D marks a double case, and Uns. one un- satisfactory as to the duration of the disease; 3d, The age; 4th, The previous health, whether good or bad, or in any way particularly affected; 5th, The day of admission, counting from the rigor, which indicates the commencement of the disease; 6th, The duration of the disease, or the commencement of the convalescent state, counting in days from the period when the rigor occurred; 7th, The number of days in the hospital after admission, or, should the disease have commenced in the hospital, count- ing from the rigor—this is a very uncertain period, which ought to re- present the duration of the convalescence, but which in many cases was lengthened by a variety of circumstances having no relation to the pneumonia; 8th, The frequency and character of the pulse on admis- sion ; 9th, The number and character of the respirations on admission; 10th, The side of the chest, and extent of pulmonary tissue involved; 11th, If complicated with other diseases it is marked by a X ; 12th, The treatment; 13th, General remarks; and 14th, The volume and page where the case may still be found. It must be remembered that the cases were not recorded in reference to any statistical inquiry, but are those drawn up by the clerks in the Clinical Wards, at the bed-side, in obedience to long-established usage. They vary greatly, therefore, in value, and in a few the information on certain points required is defec- tive. This is indicated in the Table by a note of interrogation. This Table was commenced by my former able resident physician, Dr. Glen, whose early death, as medical superintendent in the Dundee Infirmary, in 1863, deprived the profession of a singularly well-informed and highly-educated physician. It was continued by Drs. Smart, Duck- worth, and Macdonald, also my resident physicians in the Infirmary during the years 1863, 1864, and 1865, to whom I am greatly indebted for the pains they bestowed upon it. The fact that the table has been carefully revised by each of these four gentlemen in succession, affords the most convincing proof of the accuracy of its details. Tabulae View of all the Cases of Acute Pneumonia treated in the Clinical Wards of the Royal Infirmary by the Author, from 1st October 1848 to 31st January 1865, while on service for 75 months, or a computed period of 6£ years.—Average number of Beds, 40. MALE CASES. CO 00 J. Foreman J. Kell J. M'Intvre R. Hog DI F. Farrell W. Hamilton J. Conolly Previous Health. Winter cough for 3 years Good Good Good Good Good Vigorous S o oj bo to ^ Days Day, o w Days Pulse. ■ fl • 8§£l 112, hard 100, full and strong 100, good strength ', good strength Natural 100, full and hard 100, full SB'S .a H^ Q.2 9 30, la- bored Dys- pnoea Hurried and short Dys- pncea No dys- pnoea Dys- pnoea. Easy Extent, and Side involved. J lower U.S. i lower U.S. f lower L. S. £ lower L. S. J lower D. S. Both S. f upper R. S. J upper L. S. 4 lower R. S. TREATMENT. Bled before admission—amount not stated. Antimonials (1-16 gr.every 2d hour). Blis- ter afterwards. "Wine 5 vj, and nutrients. Bled to 5 xij after admission by Clerk. Antimonials (1-8 gr. every hour). After- wards blister. Nutrients. Antimony 1 gr. every hour. Afterwards expectorant mixture,nutrientsand porter. Antimony 1 gr. every two hours—then every hour. Afterwards opiates to pro- cure sleep, and 5 iij of whisky daily. Antimony 1 gr. every hour—afterwards l-16th gr. every fourth hour, combined with diuretics. Subsequently blisters. Bled, purged, blistered, etc., before admis- sion. Salines, wine Jiv, nutrients. Astringents and opiates afterwards to check diarrhoea. J- gr. antimony every third hour; wine fiv; nutrients. Cupped to 5 viij. Antimony J _gr. every four hours ; wine |vj. Blister. Quinine 1 gr. three times daily. i gr. antim. tart, every three hours. Nut- rients. Rheumatic pains treated by aco- nite locally. Observations—As to Nature of the Case—Kind of Complication— Violence of Symptoms—Peculiarity of Physical Signs—Sequelae, etc. etc. A strong laborer, with slight pleurisy, and subject to cough in winter. After bleeding entered the house exhausted- Entered a week after attack. Was bled and antimonialised. A strong man—entered soon after at- tack. Not exhausted. A strong plethoric man, addicted to drink. Convalescence commenced soon after admission, but was prolonged. A weak young man, a teacher, treated antiphlogistically before admission and convalescence further lengthened by supervening diarrhoea. Disease at first existed in middle third of right lung, and subsequently ex- tended to upper third. As pneumonia diminished, prolonged expiration and sibilant rale appeared at apex, convalescence lengthened. On the recovery of this case there supervened an attack of rheumatism, which prolonged his stay in the house Reference to Record in Hospital Case Books. Ward 1. Vol. 2, P- 201. Vol. 3, P- 6. Vol. 4, P- 141. Vol. 4, P- 166. Vol. 5, P- 119. Vol. 5 P- 93. Vol 6 P 129 Vol 7 P 111 Vol 8 P 174 . -UUUOtl D2 J. Kelly J. Stewart T. Monro H. M'Philips D3 D. Taylor A. Millar W.Gray S. Macdonald J. Donaldson vigorous Not good Vigorous Weak and gouty Good Winter cough for 22 years Good Good Good Good 111 four years Good Good Long cough Bad 106, strong 72, natural 100, full and strong 76,natural 100, strong 100, full and strong 100, small and soft 106, good 106, full 128, good strength 130, full 148, full and strong 112, good strength 120, weak Easy Dys- pnoea Hurried 26, diffi- cult Dys- pnoea Dys- pnoea 32, diffi- cult 4fi, hur- ried Hurried Dys pnoaa 30, short 56 Dys- pnoea 44, diffi- cult § lower I.. S., J lower R. S. J lower R. S. Whole of L. S. J lower R. S. i lower L, S., and J lower R.S. § lower L. S. h lower L. S. % lower R.S. A lower R. S. | lower R. S. i upper R.S. Whole of L. S. i lower R.S. f lower on both sides Salines ; blister ; nutrients. Salines; vin. colchici; nutrients. Bled to 5 xij. to relieve dyspncea. After wards 12 leeches applied. . Salines; then nutrients and wine. Pulv. opii gr. ss. every two hours. Nut- rients, wine. Antimony $ gr. every third hour, com.' bined with 1-5 grain of opium to relieve insomnolence and severe general pain, i gr. of antimony and opium every third hour. i gr. of antimony and opium every second hour. I gr., afterwards increased to J gr., of an- timony every third hour. 1 gr. of antimony every two hours. After- wards 8 leeches and a blister. Salines ; wine § viij, and nutrients. A strong young laborer, with strong pulse and rapid recovery, though both lungs were affected. A strong muscular-looking man, long subject to cough and rheumatism. The bleeding relieved dyspnoea, but caused prolonged convalescence; the length of which is not stated. A debilitated man of gouty habit, treated with opium. This case was well 18 days before dis- mission, and the cause of his deten- tion is not stated. Complicated with bronchitis and em- physema. A healthy man. Rapid recovery. This patient was convalescent 14 days after admission, and the cause of his detention is not explained. Vol. 9, p. 41. Antimony J gr. every fourth hour. Cup- ped to 5 vi. Afterwards blister applied. i gr. antimony every hour; afterwards every second hour. Antimony i gr. every three hours; after- wards nutrients. Antimony J gr. every two hours. Blis- ters, diuretics, J ij wine, and nutrients. i gr. antimony every two hours. Diu- retics, I vj wine, and nutrients. Vol. 9, P- 76. Vol. 9, P- 186. Vol. 11 >P .39. Vol. 14 P 141. Vol. 14, p. 153 Vol. 14, p. 183 Vol. 17, p. 35. Vol. 18, p. 137. Detained in the hospital 6 days after complete recovery. Had recovered from the pneumonia [Vol. 19, p. 21. 10 days after admission. Detained 73 days longer with continued fever. This was the fourth attack of pneu-. Vol. 20, p. 168. monia in four years. The former were treated antiphlogistically. Very slowj convalescence with bronchitis. Vigorous young man. Rapid recovery. Vol. 21. p. 36. A healthy boy, the date of whose con- Vol. 21, p. 92. valescence, owing to absence of daily reports, could not be determined. Recovery delayed by chronic bron- Vol. 22, p. 135, [chitis. A weak man of intemperate habits. Vol. 22, p. 131, Entered the house exhausted. Re- covery delayed. OS © o No. Name. w a < Previous Health. a h and nutrients. Complicated with typhus fever, which prolonged convalescence. Vol. 29, p. 161. 35 11. Maefarlanc 20 Good 5 12 15 104,strong 24, easy 4-5thslow-er R. S. Salines ; then diuretics Tith colchicum. An ordinary case with good recovery. Vol. 35, p. 2. 36 A. Bathgate 1)9 33 Not good 7 18 33 120, full and hard 40 f upper R. S., iuppcr L. S. Salines; diuretics with colchicum , wine 5 iv, and nutrients. A debilitated intemperate man. The pneumonia on L. S. came on 7 days after that on It. i>. Vol. 35, p. 37. 37 1>. M'i-haU 24 Weak P. Robertson D10 S. Scougie J. Adams E. Sanders Flannighan T. Doyley J. M'Farlane Dll Ed. Nugent J. Tait Uns. 2 A. Robertson D12 J. O'Donnel R.Kay D13 Robust Good Somewhat intemperate Intemperate Good Good Long subject to cough, asthma, and occasional haemoptysis Good Weak for 15 months Good 120, weak, then 128, hard and bounding 100, weak 95, weak 110, small and weak 108, small and weak 100, soft 90, good strength 95, full and strong 36, catching Dys- pnoea Much dys- pncea 36, tran- quil 40, diffi- cult 72, small and weak 112, weak 120, weak 100, full and strong ? great dys- pncea ? dys- pnoea 48 lower R. S., a lower L. S. £ lower R. S. J lower L. S. f lower L. S. Whole of R.S. i lower L. S. f lower of L. S. and JofR. S. apex. i lower L. S. J lower L. S. | upper both sides. i upper R.S. i lower L. S., i lower R.S. Salines ; blister; nutrients. quinine and cod-liver oU. Nutrients and stimulants ; wino J iv; poultices to L. S. Quietude. See p. 681. Bled to 5 xviij. Anlimonial treatment be- fore admission. Afterwards wine Jij, then 5 iv, and nutrients. Beef-tea; steak 5 vj ; and wine J iij daily, Salines, nutrients, and wine 1 iii. Salines, wine 1 iij, and nutrients. Salines combined with diuretics; wine 5 iv, and nutrients. At first, 1-16 gr. antim. tart, with 3 ss sol. ammon. acet. every six hours. Cupped on chest, and \ iv of blood extracted to re- lieve dyspnoea. Afterwards ? iv of wine daily with nutrients. Rheumatism treat- ed by alkalies internally. Stimulants to relieve spasm and overcome collapse ; then nutrients, and wine I iv daily. See p. 685. 5 iv wine and ? ij of whisky in 24 hours. Nutrients ad lib. Diuretics ; ? iv wine, and nutrients. Wine 5 iv daily; liquid nutrients ad lib.; slight salines. Salines; nutrients; wine ? iv. This case was one of pleurisy. Pneu- monia came on in the ward on the 7th day. Convalescent on 17th day of pneumonia, but pleurisy continued. A strong man, with great dyspnoea and lividity of face threatening suffo- cation, which diminished in two days. The treatment before admission led to prostration and prolonged conva> lescence. In an attack at Glasgow 7 months be- fore, was bled, mercurialized, etc., and recovered slowly, with great weakness. On this occasion recovered rapidly. A weak person. This case now cannot be found- missing. A simple case. -book A thin weak-looking man. Hadehron ic phthisis for ten years. All the pneumatic symptoms violent, and the physical signs well marked (an exqui- site case), followed by acute rheuma- tism, which prolonged his residence in the house. A strong healthy-looking man. Seized with spasm of stomach and great weak- ness. Entered the house an hour after- wards. Rallied by rest and stimulants. On the third day pneumonia estab- lished. Rapid and complete recovery. Detained in the house on account of chronic rheumatism and acute lichen. Phthisical symptoms preceded attack, which disappeared. The pneumonia was at the apex, but recovered rapidly. The pneumonia began and was most severe on the left side. There was a little pleurisy. Vol. 35, p. 192.| Vol. 32, p. 213 Ward 2, vol. 8, p. 16. Ward 2, vol. 1 p. 20. Ward 1, vol. 39, p. 37. Vol. 41, p. 11, Vol. 41, p. 4. Vol. 40, p. 1. Vol. 43, p. 169. Vol. 40, p. 68. Vol. 40, p. 75. Vol. 42, p. 137, ~1 O o P. M'Shim D 14 W. Purdie D15 W. Sword D16 C. Hazard J. M'Donald D17 J. M'Lauchlin J. Baker D18 F. Joyce D19 F. Flinn J. Bain J. Kitchen J. Doran Previous Health. s s>:g.sp cJ t> ' Good Good Good Good Good Good 57 Bad 19 Good 21 Good 25 Good 47 Good 40, Good Days Days Days 3 | 10 26 2 10 9 11 10 16 10 7 12 8 7 14 16 sSsg 8£ 2 :5S£ S o to a+s lis el t> H 'If 2 Extent, and Side involved. Q w ■< U 3 P4 O o X TREATMENT. Observations—As to Nature of the Case—Kind of Complication— Violence of Symptoms—Peculiarity of Physical Signs—Sequelae, etc. etc. Reference to Record in Hospital Case Books. Ward 1. i "8 ■ -?§H a 1° 79 80 81 82 83 84 85 Geo. Fleming John Devine A. Henderson J. Welch J. Duffie Mich.Brannen John Bell Not good Good Good Good Occasional Bronchitis Good Good 1 7 8 3 6 6 5 9 10 13 10 9 11 12 25 8 13 14 10 14 15 98, weak 98, weak 96, full, of good strength 70, soft 108, strong 90, weak 96, fan-strength 30 40, dys-pncea 24, no dys-pnoea 27 28 34 48, dys-pnoea £ lower L.S. $ lower R.S. £ lower L. S. 4 lower L.S. * lower L.S. $ lower R. S. i lower L. S. Nutrients; wine ?vj, Nutrients; wine 5 vj. Nutrients; wine 5 iv. Salines; poultices to side; ? iv of wine for two days. Blister to side subsequent-ly-Salines; beef-tea. Salines; nutrients; 5 vj wine. Salines ; nutrients ; ? viij wine. The pneumonia followed a severe and prostrating attack of rubeola. A strong man—rapid recovery. Strong healthy man. Diarrhoea on admission. Yeast-like stools up to 15th day from rigor. A healthy man, given to spirit-drink-ing. Formerly had pleuro-pneumo-nia. Much bronchitis, which completely disappeared. Much bronchitis. Exhausted by star-vation previous to admission. Second attack of pneumonia. Habits intemperate. Vol. 57, p. 25. Vol. 57, p. 71. Ward 10, vol. 4, p. 13. Ward 1, vol. 60, p. 75. Vol. 59, p. 76. Vol. 61, p. 217. Vol. 60, p. 154. FEMALE CASES. Ward 11. 86 87 88 89 90 S. Flynn Uns. 5 M. Dixon Uns. 6 E. M'Cormack D24 A. Connor D27 A. Donally 14 42 40 9 20 111 3 months 111 8 weeks ? Not good, emaciated Long had bronchitis 6 ? 8 8 1 1 19 20 21 10 18 32 20 42 12 120, small 121, soft 126, hard 132, soft 100, full Dys-pnoea. J Sup-pressed. Hurried Dys-nncaa | lower L.S. i lower R. S. t lower R. S., 4 lower L. S. J lower R. S., i up-per L. S. * lower R. S. Bled to 5 xij on admission. £ gr. antim. tart, every two hours. Salines; blister. £ gr. antim. tart, every second hour; blister. Tr. digital. fllv every four hours; laxa-tives ; afterwards 3 leeches to side to re-lieve pain. 8 leeches; I gr. antim. tart, every hour, with t gr. pulv. opii. Record defective. Commencement of convalescence cannot be determined. Commencement of pneumonia not stated. Previous health not stated. Great exhaustion and unusual action of the heart in this case. Strength good in this case on admis-sion. Vol. 1, p. 75. Vol. l,p. 131. Vol. 3, p. 60. Vol. 3, p. 105. Vol. 0, p. 103. I 01 11. Cowan Uns. 7 26 Consh and dyspnona for 8 months • 3 32 11', wea i Dys-pnoea. t low...-It. S. 92 M. Carle 15 T 5 10 8 100, full Dys-pnoea. } lower R. S. 93 M. Dickson 34 1 8 19 25 101, tjood strength Urgent dys-pnoea $ lower R. S. 94 B. White D26 28 1 8 13 5 92, strong Dys-pnoea i lower both sides 95 B. Reynolds 26 ? 5 15 23 120, full and strong Hurried f lower R. S. 96 C. M'Donald 15 Cough for a month 1 10 25 120, soft and weak 36 Whole of L. S. 97 M. Hodges 38 Good 7 16 23 S0,strong and full Difficult Whole of L. S. 98 M. M'Donald 20 Feeble 10 18 24 66, weak No dys-pnoea $ lower R. S. 99 J. Smith Uns. 8 13 1 10 1 14 80, strong ? „■ lower R. S. 100 H. BaUoch 18 Rheumatio 1 19 102 100, mo-derate strength 46 1 lower L.S. 101 M. Ross 35 Subjeot to coughs 3 16 53 104, weak Labored $ lower L.S. 102 A. Smith 32 Weak 9 26 23 78, weak i | lower L.S. 103 M. Corrigan 25 Good 5 14 18 96, strong » } lower L.S. 104 M. Kay 40 Not good 6 18 43 106, weak 1 | lower R.S. 105 C. M'Lean 16 Good 7 17 42 120, soft 1 f lower R. S. 106 M, M'Donald 40 Weak 2 8 31 130, full and strong 32 to 86, hurried f lower L. S. Wine | iv ; J gr. anrlm. tart, every four hours; 8 leeches afterwards to relieve pain. 12 leeches to painful side: J gr. antim tart, every three hours ; blister, i g. of antimony with J gr. of opium to relieve pain; diuretics; subsequently 12 leeches and 2 blisters were applied. Salines ; 8 leeches and blister; wine J vj 1 gr. antimony every two hours; discon- tinued after 24 hours; afterwards 12 leeches were applied; wine, § vj ; blister. Salines; 8 leeches, and afterwards blis ters were applied. 1 gr. antimony every four hours, and a blister applied to the side. Salines; ? iij wine and nutrients, with i gr. of tartar emetic. Blister to right side Salines and nutrients. f gr. of antimony every four hours; a blister; wine 5 iv, increased to 1 vj, and nutrients. Rheumatism treated with diuretics and anodynes. Salines with small doses of morphia; blisters ; J viij wine. 1 gr. tartar emetic; 3 gr. calomel daily for a week; 4 leeches ; salines; wine J vj; 7 leeches; nutrients. Slight salines; blister applied ; and wine 5 iij. £ gr. of antimony every two hours; blis- ters applied; afterwards diuretics. Antimony $ gr. and diuretics. Antimony | gr. every third hour; after- wards diminished to \ gr. every fourth hour; 8 leeches. The previous illness caused com menccment of pneumonia to be unde- termined. Considerable pain in side—relieved by leeches. Previous health not stated. Previous health not stated. General health probably enfeebled by previous nursing. Very weak after subsidence of febrile symptoms. A simple pneumonia, with unretarded recovery. No indication for wine Rigors and cough, but no physical signs on admission. These appeared on 4th day. Subject to occasional cough and pain in the chest before the attack. Had not been under treatment be- fore admission, though ten days had elapsed since the rigor. Acute rheumatism and cardiac disease detained her in the hospital. Pleu- ro-pneumonia commenced two days after admission. Diarrhoea in the course of conva- lescence, which was prolonged. In weak health previously. Period rather long before convalescence oc- curred. A simple pneumonia in a previously healthy woman. A weakly woman, allowed to linger too long in the hospital. Detained in the hospital on account of pleurisy. , This patient was a night nurse, and suffered from debility and leucorrhcea Vol. 6, p. 20:'. Vol. 7, p. . Vol. 8, p. 93. Vol. 9, p. 7. Vol.9, p. 110. Vol Vol, Vol. Vol. Vol, Vol. Vol. Vol, Vol Vol Vol, 11, p. 14. , 12, p. 46. , 12, p. 119. , 13, p. 152. , 14, p. 28. 16, p. 74. 17, p. 120. 17, p. 165. , 19, p. 15. ,19,p. 123. 19, p. 159. g s g 112, bounding , not strong 92, soft and jerk- ing 105, com- pressible 120, weak , weak 96, weak 120, weak 96, weak 150, small 100, small and weak O OS p\S £ a) an 40, hur- ried Dys- pnoea, 52, la- bored 22, easy Urgent dys- pnoea Dys- pnoea 30, dys- pncea Dys- pnoea. Dys- pnoea. 56, ur- gent dys- pnoea Dys- pnooa Extent, and Side involved. i lower L. S. i upper R.S. J lower L.S. # lower R.S. D. f lower R. S. i lower R, S., A mid- dle L.S. f lower R.S. | lower L. §., | lower R.S. f lower R. S. Whole of L. S. J lower L, S., i up- per R. S. TREATMENT. Observations—As to Nature of the Case—Kind of Complication— Violence of Symptoms—Peculiarity of Physical Si c. ad 1 vj. M. One table-spoonful to be taken three times a day. July 24th.—Urine still highly albuminous and scanty, though diuretics have been freely given, including supertartrate of potass. Liver now much larger, and extends down to Poupart's liga- ment when she sits up. GEdema has extended above the knee. Weakness has in- creased. August 16th.—Has continued in the same exhausted condition, every care having been taken to support her strength by small quantities of nutritious food. She has experienced little pain, and latterly obtained sleep at night by ether and morphia draughts. At 4 a.m. this morning, respiration became very difficult, and shortly after she died. * Reported by Mr. Bum Murdoch, Clinical Clerk. 732 DISEASES OF THE RESPIRATORY SYSTEM. Sectio Cadaveris.—Thirty-one hours after death. Body greatly emaciated. Thorax.—Both pleura? strongly adherent throughout by chronic adhesions. Apices of both lungs much puckered externally. The whole of the superior lobe of left lung hollowed out so as to form a cavern the size of a large cocoa-nut, containing foetid air and about four ounces of dirty pus. Its walls were fined by a distinct pyogenic membrane, and consisted externally only of thickened pleura, and internally of a layer of indurated lung about half an inch in thickness. In the inferior lobe were several masses of infiltrated tubercle, which in some places were softened, forming small purulent collections, varying in size from a pea to that of a hazel nut. Through- out the upper lobe of right lung there were a few excavations, quite dry, varying in size from a millet seed to that of a small nut. The parenchyma between these was much indurated by chronic pneumonia, and of an iron-gray color from pigmentary deposits. At the apex were several cretaceous concretions about the size of peas. One of these was the size of an almond nut, elongated in form, and all were enclosed in indurated capsules. The two inferior lobes were emphysematous anteriorly. In the centre of the lowest one was an indurated white patch, the size of hdf-a-crown, with radii stretching from it in all directions. On cutting through it, it was seen to con- sist externally of dense white fibrous tissue, an eighth of an inch in thickness, and immediately below it was a mass of indurated tubercle, the size of a hazel nut, of iron-gray color, containing gritty points of cretaceous matter. Other similar masses of varying size, but widely scattered, gave a nodulated feel to the two inferior lobes on this side. Heart healthy. Abdomen.—The liver was not only enlarged, but altered greatly in shape. The right lobe was so elongated as to extend down to the crest of the ilium. The length from above downwards was 12 inches ; breadth 8 inches. Length of left lobe was 8 inches; breadth, 5 inches. Its entire weight was 7 lbs. 9 oz. The greatest thickness of the organ from behind forwards was four inches. In texture it was of waxy con- sistence and appearance, of a dirty yellow color, dense feel, smooth section, presenting semi-translucent edges. The spleen weighed 1 oz. 5 dr., and was healthy. The mucous membrane of the caecum was of a black tint, which extended up the ascending and half way across the transverse colon, gradually diminishing in intensity. This dis- colored portion of the membrane was studded over with chronic tubercular ulcers in various stages of healing, mingled with numerous cicatrices and puckerings. The largest of the open ulcers were the size of a shilling, with irregular raised edges, and dirty yellowish base. Mesenteric glands everywhere enlarged, of a white color and in- durated ; some contained tubercular deposits. Both kidneys waxy; externally pale, indurated, and rough ; internally, cortical substance atrophied, pale, and on section having translucent edges. The uterus contained in its inferior wall a fibrous tumor the size of a walnut. Three others the size of peas were on its anterior surface; ovaries contracted, rugose, and of semi-cartilaginous consistence. Other organs healthy. Microscopic Examination.—The tubercle everywhere presented its usual charac- ters. The cells of the liver had undergone a remarkable change, being colorless, re- refracting light, deprived of nuclei, and forming, when compressed together, a trans- lucent, amorphous mass. The black matter in the caecum was composed of molecules and irregular masses of black pigment. Commentary.—This case of chronic phthisis, which we watched for nine months, appeared to be on the point of death when she entered the Infirmary. The prostration was extreme, an enormous excavation even then existed in the left, with smaller ones in the right lung. Careful treatment directed to restore the tone of the stomach, nutrients adminis- tered in small quantities, with wine and cod-liver oil, caused a gradual restoration, and my opinion is, that from that time the pulmonary dis- ease continued to diminish. The cavities on the right side became dry, cicatrices and cretaceous transformations of the tubercular matter pro- ceeded, and the large excavation on the left side became smaller and more circumscribed. The liver first, and then the kidneys, underwent the waxy transformation; cedema came on, and she sunk. I have already alluded to the peculiar character of this degeneration of the liver PHTHISIS PULMONALIS. 733 and kidney (p. 249). It is exceedingly common in phthisical cases, and in this instance was recognised and examined histologically with great care in 1815. Formerly it was confounded with fatty degeneration, and it has been supposed that cod-liver oil tends to its production. But a knowledge of the true nature of the waxy degeneration must negative such a supposition, as the liver is altogether free from fat. The inter- ruption to the portal and renal circulations, and the diminished flow of urine, produced more or less anasarca, a complication which sooner or later is uniformly fatal. ■ The previous cases illustrate tolerably well the advantages which attend what may be denominated a curative, as distinguished from a palliative, treatment of phthisis. It is exceedingly rare, however, that we can demonstrate among hospital cases a complete cure of the disease in its advanced stage, such as took place in Barclay. (Case CLVII I.) In the majority of instances, no sooner is amendment effected, than they insist on going out. A few return with the disease advanced, again get better, and so on, until at length they die. Many others I am satisfied get perfectly well. In private cases, however, recovery is much more frequently observed; and now that physical diagnosis has enabled us with great certainty to recognise the disease and follow its progress, we can have no doubt of the superior advantages of a curative over a pal- liative practice. To carry out the former, however, upon correct prin- ciples, it is proper to have a knowledge—1st, Of the natural progress of the disease; 2d, Of its pathology and general treatment; and 3d, Of the special treatment, in reference to symptoms and complications. It may be well to make a few observations on each of these heads. I.— On the Natural Progress of Phthisis Pulmonalis—The Tendency to Ulceration—The modes of Arrestment. At first tubercle is deposited in the state of a fluid exudation from the capillaries in the same manner that lymph is. In this condition it insinuates itself into the interstices of the pulmonary parenchyma, passes through the lining membrane of the air vesicles, and fills their interior. Numerous successful injections of pneumonic, tubercular, and cancerous lungs, in my possession, demonstrate that the exudation in all is poured out in the same manner, and occupies the same position in the pulmo- nary texture. A miliary tubercle may, in this manner, block up from three to twenty of these air vesicles (Figs. 160,161). It now coagulates and constitutes a foreign solid body, which can only be removed by being again broken down and rendered capable of being either absorbed or excreted. Thus the miliary or infiltrated forms, whether gray or yellow, after a time soften,—a process which may commence at any part of the mass and gradually affect the whole. This softening is a disintegration or slow death of the tubercular exudation, constituting true ulceration, which is more or less extensive according to the amount and extent of the morbid deposit. (Figs. 157, 158, and 159.) When recent, the pulmonary parenchyma in the immediate neighbor- hood is more or less congested; and when chronic, it is thickened and 734 DISEASES OF THE RESPIRATORY SYSTEM. indurated, often forming a capsule which surrounds the tubercular de- posit. The pleura also is very liable to be affected; when recently so, presenting soft fibrinous exudations with more or less adhesion; where- as when chronic, these become fibrous, and reach a thickness and den- sity seldom seen in other diseases. The bronchi are necessarily in- Fig. 457. volved; their extremities are among the first structures affected; and as the tuberculosis proceeds, all the appearances characteristic of chronic Fig. 457. Section of a lung in the first stage of Phthisis Pulmonalis. Ulcerative softening is commencing at the apex. Two-thtrds the real size. PHTHISIS PULMONALIS. 735 bronchitis are produced. As the ulcerative process extends, the lung is more and more destroyed, the excavations become larger and more numerous (Figs. 458, 459), until at length it can no longer carry on its important functions, and the patient dies, or the fatal result, as Very commonly happens, is hastened by disease in other organs. The ulcerative or destructive tendency of the tubercular exudation Fig. 458. has generally been supposed to be its chief characteristic; but there are Fig. 458. Section of a lung in the second stage of Phthisis Pulmonalis. Tubercle is extensively infiltrated in the upper lobe, and a considerable cavity has formed. Two-thirds the real size. 736 DISEASES OF THE RESPIRATORY SYSTEM. very few cases in which its progress is uniform. It is continually checked, and for a time slumbers; and all morbid anatomists have recognised, even in the worst specimens of tubercular lungs, numerous cicatrices and evidences of attempts to heal. These attempts are more or less .perfect, and when ineffectual, it is owing to the circumstance that as one portion of lung cicatrizes, another becomes the seat of recent tubercle. Fig. 459. Cicatrices present different appearances, according as the cavities Fig. 459. Section of a lung in the third stage of Phthisis Pulmonalis. A cavity occupies the superior half of the organ, and another smaller one has formed in the inferior lobe. Two-thirds the real size. PHTHISIS PULMONALIS. 737 from which they were formed have been superficial or deep seated. In the first case it will generally be observed that the pleurae are more or less adherent and thickened, and this frequently forms an external boundary to the tubercular cavity. As the matters which the cavity con- tains are expectorated or transformed, the lymph gradually contracts, draws the hxr\; in it by the operation of the blood glands "ft jgft - / j © and the lungs. No one can doubt that the '"'' ' ^% oil and the albumen so derived from the food, and so altered chemically and mechanically in the body, constitute the material from which blood is formed; neither can there be any question that the presence and emulsionising of these elements in proper proportions, are absolutely necessary to supply and keep up the vital properties of the blood. Fi» 462 Chyle from the thoracic duct of a dog, three hours after eating a meal. a, Fluid chyle showing its molecular basis, and corpuscles in various stages of devel- opment into those of blood, b, Corpuscles of chyle embedded m fibrillated fibrin. Thev are round in the centre, but more or less compressed and elongated towards the mo^-„ 250 diam. margin. 744 DISEASES OF THE RESPIRATORY SYSTEM. The peculiarity of phthisis, however, is, that an excess of acidity exists in the alimentary canal, whereby the albuminous constituents of the food are rendered easily soluble, whilst the alkaline secretions of the saliva and of the pancreatic juice are more than neutralized, and rendered incapable either of transforming the carbonaceous constituents of vegetable food into oil, or of so preparing fatty matters introduced into the system, as will render them easily assimilable. Hence an in- creased amount of albumen enters the blood, and has been found to exist there by all chemical analysis, while fat is largely supplied by the ab- sorption of the adipose tissues of the body, causing the emaciation which characterises the disease. In the meanwhile, the lungs become especially liable to local congestions, leading to exudation of an albuminous kind: which is tubercle. This, in its turn, being deficient in the necessary proportion of fatty matter, elementary molecules are not formed so as to constitute nuclei capable of further development into cells; they therefore remain abortive, and constitute tubercle corpuscles. Thus a local disease is added to the constitutional disorder, and that compound affection is induced which we call phthisis pulmonalis, consisting of symptoms attributable partly to the alimentary canal, and partly to the pulmonary organs. To improve the faulty nutrition which originates and keeps up the disease, it is of all things important, therefore, to cause a larger quantity of fatty matter to be assimilated. A mere increase in the amount, or even quality, of the food, will often accomplish this, as in the case of Keith. The treatment practised some years ago by Dr. Stewart of Erskine, which consisted in freely administering beef-steaks and porter, and causing exercise to be taken in the open air, excited considerable attention from its success. I have been informed, that in some parts of America the cure consists in living on the bone marrow of the buffalo, and that the consumptive patient gets so strong in this way, that he h at length able to bunt down the animal in the prairies. All kinds ( food rich in fat will not unfrequently produce the same effects, and hence the value long attributed to milk, especially ass's milk, the produce of the dairy, as cream and butter, fat bacon, caviar, etc. But in order that such substances should be digested and assimilated, the powers of the stomach and alimentary canal must not have under- gone any great diminution. In most cases it will be found that the patient is unable to tolerate such kind of food, and that it either lies un- digested in the stomach, or is sooner or later vomited. Under these circumstances, the animal oils themselves are directly indicated, by giving which, we save the digestive apparatus, as it were, the trouble of manufacturing or separating them from the food. By giving consider- able quantities of oil directly, a large proportion of it is at once assimi- lated, and is rendered capable of entering into combination with the albumen, and thereby forming those elementary molecules so necessary for the formation of a healthy chyle. Such, it appears to me, is the rationale of the good effects of cod-liver oil. Since I introduced this substance to the notice of the profession in this country as a remedy for phthisis, in 1841, I have continually pre- scribed it in hospital, dispensary, and private practice. I need not per- * PHTHISIS PULMONALIS. 745 haps say, that I have given it in a very large number of cases, and have observed its effects in all the stages of the disease, and under almost every circumstance of age, sex, and condition. I have had the most ex- tensive opportunities of examining the bodies of those who have died after taking it in considerable quantities, and am still observing the cases of many persons who may be said to have owed their lives to its employ- ment. Further, I have carefully watched the progress it has made in the good opinion of the professional public, and perused all that has been published regarding it in the literature of this and other countries. It were certainly easy for me, therefore, to write at great length on this subject; but I do not see that anything of utility could be added to what I have already published. The following is a summary of my views regarding cod-liver oil as a remedy for phthisis:— 1. Cod-liver oil is, as M. Taufflied pointed out, an analeptic {p.va\a.p.fiav(t>, to repair), and is indicated in all cases of abnormal nutrition dependent on want of assimilation of fatty matter. 2. It is readily digestible under circumstances where no other kind of animal food can be taken in sufficient quantity to furnish the tissues with a proper amount of fatty material. 3. It operates by combining with the excess of albuminous consti- tuents of the chyme, and forming in the villi and terminal lacteals those elementary molecules of which the chyle is originally composed. 4. Its effects in phthisis are to nourish the body, which increases in bulk and in vigor; to check fresh exudations of tubercular matter, and to diminish the cough, expectoration, and perspiration. 5. The common dose for an adult is a table-spoonful three times a day, which may be often increased to four, or even six, with advantage. When the stomach is irritable, however, the dose to commence with should be a tea or dessert-spoonful. 6. The kind of oil is of little importance therapeutically. The pure kinds are most agreeable to the palate; but the brown coarser kinds have long been used with advantage, and may still be employed with confidence whenever cheapness is an object. 7. I have never observed its employment to induce pneumonia, or fatty disease of the liver or kidney, however long continued, although such complications of phthisis are also exceedingly frequent. But in some rare cases the oil cannot, even under the best manage- ment, be retained on the stomach, and efforts have been made to intro- duce fat into the economy by some other channel, such as by the skin and rectum. The former plan was first tried by Dr. Baur of Tubingen, who rubbed various kinds of oil into the skin, and even recommended oil baths. Persons occasionally got better under this as they do under every other kind of treatment, but the excessive trouble, and sense of unclean- liness which greasy frictions occasion, are strong objections to its use. Its costliness also renders it inapplicable to the poor. Oily enemata were recommended by Dr. Buist of Aberdeen. But it must be evident that as nature never intended mankind to be permanently nourished either by the skin or by the rectum, so, in imitation of her processes, the object of an analeptic treatment in pulmonary tuberculosis must be to cause the elements of the food to be taken by the mouth; to diminish 746 DISEASES OF THE RESPIRATORY SYSTEM. the dyspeptic symptoms, and induce assimilation by the lacteal rather than by the lymphatic vessels. 2. The second indication—namely, to subdue local irritation—is only to be followed out in acute cases by much the same practice as guides us in the treatment of pneumonia, which is the general cause of such irrita- tion. From what has been previously said on that subject, it must be evident that, however practitioners may flatter themselves that by bleed- ing or mercury they have checked inflammation, these remedies in phthisis, so far from arresting the local lesion, have only accelerated it. In the chronic forms of the disease this indication is only to be met by topical counter-irritation. Hence a seton or issue, a succession of blisters, tartar emetic ointment, and croton oil, are all beneficial, and may be used according to circumstances. Cold sponging, employed with great precaution, so as not to produce a chill, but rather a glow of heat afterwards, is also beneficial. Such are the only means in our power to meet this important indication, because, combined with this local lower- ing treatment, the general system must be invigorated to the utmost. This is the difficult problem to be worked out in the treatment of phthisis, and in doing so we shall be much assisted by paying particular attention to the third indication. 3. The avoidance of those circumstances likely to deteriorate the constitution on the one hand, or induce pulmonary symptoms on the other, offers a wide field for the judicious practitioner, especially in his character as a watchful guardian over his patient's health. One of the great difficulties we have to overcome in this climate, is the frequent variations of temperature, and the sudden changes from fervent heat to chilling cold. Supposing that you have the means of supporting nutri- tion and keeping down local irritation, it is by no means certain that good will be accomplished, from the impossibility of securing those hygienic regulations and that equable climate, which are necessary to carry out the third indication. In the first place, nutrition itself is more connected with proper exercise and breathing fresh air than many people imagine. It does not merely consist in stimulating the appetite and giving good things to eat. It requires—1st, Food in proper quan- tity and quality; 2d, Proper digestion ; 3d, Healthy formation of blood; 4th, A certain exchange between the blood and the external air on the one hand, and between the blood and the tissues on the other; and 5th, It requires that there should be proper excretion, that is, separation of what has performed its allotted function and become useless. All these processes are necessary for nutrition, and not merely one or two of them, for they are all essentially connected with, and dependent on, one another. Hence the means of prevention consist in carrying out those hygienic regulations which secure the performance of these differ- ent nutritive acts, the most important of which are attention to climate, exercise, and diet. Much has been written on climate, but the one which appears to me best is that which will enable the phthisical patient to pass a few hours every day in the open air, without exposure to cold or vicissitudes of PHTHISIS PULMONALIS. 747 temperature on the one hand, or excessive heat on the other. Whenever such a favored locality may be found during the winter and spring months, its advantages should be considered as dependent on exercise, and on the stimulus given to the nutritive functions, rather than to its influence on the lung^ directly. The great mass of those affected with phthisis, however, have not the means of searching out a favorable climate on the Continent, or even of maintaining themselves in a sheltered nook on the western or south- western coasts of this country. It has, therefore, been proposed that such buildings as the Crystal Palace should be converted into winter gardens and public promenades. Not to speak of the intellectual and recreative purposes that such a plan would subserve, it is worthy of our consideration how far it would tender to promote health in general, but especially, how it would conduce to the cure of phthisis. Its great ad- vantage would be offering the means of exercise in a pure atmosphere, at an equable temperature. It is easy for us, by confining patients in a suite of rooms in which the heat is regulated, to secure immunity from cold and change of air ; but such a contrivance is most intolerable to the patient; the mind becomes peevish, which in itself is a powerful obstacle to the proper performance of the digestive functions. But above all, the body is deprived of exercise—that necessary stimulus to the appetite, respiration, and other functions. Some years ago, I succeeded in confining a consumptive patient to his room for an entire winter. His spirits suffered greatly; but on the whole he supported the imprison- ment with resolution. Next winter, however, nothing could induce him to remain at home, and one day he rushed out of the house, ascended Arthur's Seat, and was much better in consequence. Since then I have been convinced that, although by confinement you may gain some ad- vantages, on the whole it is a prejudicial practice if rigorously carried out. What is required in these cases is the means of exercise, whether on foot, on horseback, or in a carriage, where the patient is protected from cold winds, and where the mind can be amused by pleasant sights and cheerful conversation. Such is the case in all those favored localities considered bast for consumptive people, and such would be the advan- tages derived from resorting to the Crystal Palace as a winter garden and promenade. Delicate individuals could be transported there by means of a close carriage, in the worst seasons, without difficulty, and on entering it could breathe for hours a pure> balmy air, meet their friends, take exercise in various ways, read, work, or otherwise amuse themselves. Such an out-door means of recreation, combined with careful hygienic regulations at home, would go far to remove many of the difficulties which we have to encounter in the ordinary treatment of consumption. With regard to diet, it may be said, in general terms, that one of a nutritious kind, consisting of a good proportion of animal food abound- ing in fat, is best adapted for phthisical cases, whilst everything that in- duces acidity should be avoided. But, as previously stated, the difficulty consists in causing such diet to be taken, on account of the bad appetite and dyspeptic or febrile symptoms which prevail. No effort, therefore, should be spared to overcome the obstacles which prevent food of suffi.- 748 DISEASES OF THE RESPIRATORY SYSTEM. cient quality and quantity from being digested, the appropriate means for doing which must vary according to the circumstances of the case, and will be treated of immediately. The strongest stimulus to the appe- tite, however, is exercise, and hence the importance of the considerations already entered into, with reference to securing what is essential in the treatment of the disease, namely, good digestion and proper assimilation. If the pathology of pulmonary tuberculosis formerly described be correct, it indicates what are the means best adapted for preventing as well as arresting the disease when it has already commenced. These are, for the infant, a healthy nurse, cleanliness, and careful attention to all those circumstances which tend to increase the bodily vigor and to secure good digestion. At the time of weaning and of teething, the most watchful care becomes necessary, so that local irritation and its effects may be prevented as much as possible, and a proper diet, contain- ing a sufiicient amount of the fatty principles, be taken. During ado- lescence, indulgence in indigestible articles of food should be avoided, especially pastry, unripe fruit, salted provisions, and acid drinks, while the habit of eating a certain quantity of fat should be encouraged, and, if necessary, rendered imperative. The same precautions, conjoined with proper bodily and mental exercise, avoiding exhausting and too fatigu- ing occupations, should subsequently be maintained until the predisposi- tion to tubercular disease has been completely overcome. In short, every- thing that can support and invigorate should be adopted, and everything that can exhaust and depress should be shunned. As vitiation of the chyle and blood precedes the local deposition of a tubercular exudation, it necessarily follows that the numerous class of delicate invalids whose chief complaint is derangement of the digestive process, with languor and debility, may, by the hygienic means now indicated, and proper treat- ment of the dyspepsia, be restored to health. Were it possible in all cases for these three indications to be carried out, I feel satisfied the cure of phthisis would be more frequent; but in the treatment of this disease, the physician has to struggle not only with the deadly nature of the disorder, but with numerous difficulties over which he has no control, such as, among the poorer classes, the impossi- bility of procuring good, diet, and the thousand imprudences not only they, but the majority of invalids, are continually committing. Then another great difficulty is, to convince the patient that, notwithstanding the removal of his urgent symptoms, the disease is not cured, and that these will return, if the causes which originally produced them are again allowed to operate. Sometimes I have found it difficult to keep hospital patients in the house when they are doing well, at other times they are sent out in accordance with certain regulations, which oblige the admission of more acute cases. This was the case with Barclay. (Case CLVIII.) So long as he was under treatment, or rather enjoyed the comforts and good diet of the Infirmary, so long was he well. But sent out, exposed to misery, to insufficient food, and work, he became worse. Lastly, the attempt to relieve distressing symptoms interferes much more than is generally supposed with the curative treatment. This leads me to speak of the PHTHISIS PULMONALIS. 749 III.—Special Treatment of Phthisis Pulmonalis. Under the head of General Treatment of Phthisis Pulmonalis, I have pointed out the means of meeting the three indications which should never be lost sight of in this disease. But every case requires a special treatment in addition, which will depend on the unusual severity of this or that symptom, or the existence of peculiar complications. It is to the undue importance given to this special, as distinguished from the general treatment, that I attribute much of that want of success experi- enced by practitioners. Thus it is by no means uncommon to meet with patients who are taking at the same time a mixture containing squills and ipecacuanha to relieve the cough; an anodyne draught to cause sleep and diminish irritability; a mixture containing catechu, gallic acid, tannin, or other astringents, to check diarrhoea; acetate of lead and opium pills to diminish haemoptysis; sulphuric acid drops to relieve the sweating; and cod-liver oil in addition. I have seen many persons tak- ing all these medicines and several others at one time, with'a mass of bottles and boxes at the bedside sufficient to furnish an apothecary's shop, without its ever suggesting itself apparently to the practitioner, that the stomach drenched with so many nauseating things is thereby pre- vented from performing its healthy functions. In many cases there can be little doubt that this treatment of symptoms, with a view to their palliation, whilst it destroys all hope of cure, ultimately fails even to relieve the particular functional derangement to which it is directed. Still these symptoms require attention; but their causes, and the means required for their relief, will be best understood by speaking of each in succession. Cough and Expectoration.—At first the cough in phthisis is dry and hacking. When tubercle softens or bronchitis is present, it becomes moist and more prolonged. When excavations exist, it is hollow and reverberating. In every case cough is a spasmodic action, occasioned by exciting the branches of the pneumogastric nerves, and causing simulta- neous reflex movements in the bronchial tubes and muscles of the chest. The expectoration following dry cough is at first scanty and muco- purulent, and afterwards copious and purulent. ' When it assumes the nummular form—ihat is, occurs in viscid rounded masses, swimming in a fluid clear mucus—it is generally brought up from pulmonary exca- vations. The accumulation of the sputum in the bronchial tubes is an excitor of cough; and hence the latter symptom is often best combated by those means which diminish the amount of sputum. When, on the other hand, the cough is dry, those remedies should be used which diminish the sensibility of tho nerves. In the first case, the amount of mucus and pus formed will materially depend on the weakness of the body, and the onward progress of the tubercle. Hence good nourish- ment and attention to the digestive functions are the best means of check- ing b.)th the couo-h and the expectoration; whereas giving nauseating mixtures of ipecacuanha and squills is perhaps the worst treatment that can be employed. There is no point which experience has rendered me more certain of than that, however these symptoms may be palliated by cough and anodyne remedies, the stomach is thereby rendered intolerant 750 DISEASES OF THE RESPIRATORY SYSTEM. of food, and the curative tendency of the disease is impeded. On the other hand, nothing is more remarkable than the spontaneous cessation of the cough and expectoration on the restoration of the digestive func- tions and improvement in nutrition. When the cough is dry, as may occur in the first stage, with crude tubercle, and in the last stage, with dry cavities, counter-irritation is the best remedy, employed in various forms. Opium may relieve, but it never cures. The occasional use of the sponge saturated in a solution of nitrate of silver, is frequently of the greatest service. (See Laryngitis.) Loss of Appetite.—This is the most constant and important symptom of phthisis, inasmuch as it interferes more than any other with the nutritive processes. If food, or the analeptic, cod-liver oil, cannot be taken and digested, it is vain to hope for amelioration in any of the essential symptoms of the disease. Hence we should avoid a mistake into which the inexperienced are very liable to fall. Nothing is more common than for phthisical patients to tell their medical attendants that their appetite is good, and that they eat plentifully, when more careful inquiry proves that the consumption of food is altogether inade- quate, and that they loathe every kind of animal diet. In the same manner, they say they are quite well, or better, when they are evidently sinking. We should never be satisfied with general statements, but determine the kind and amount of food taken, when sufficient proof will be 'discovered, in the vast majority of cases, of the derangement, formerly alluded to, of the appetite and digestive powers. Very com- monly also, there will be acid and other unpleasant tastes in the mouth. In all such cases, especially if too much medicine has been already given, the stomach should be allowed to repose itself before anything be ad- ministered, even cod-liver oil. Sweet milk, with toasted bread, and small portions of meat nicely cooked, so as to tempt the capricious ap- petite, should be tried. Then ten drops of the Sp. Ammon. Aromat., given every four hours in a wine-glassful of some bitter infusion, such as that of Calumba or Gentian, with a little Tr. Aurantii, Tr. Cardamomi, or other carminative. In. this way the stomach often regains its tone, food is taken better, and then cod-liver oil may be tried, first in tea- spoonful doses, cautiously increased. Should this plan succeed, amelio- ration in the symptoms will be almost certainly observed. Nausea and Vomiting.—Not unfrequently the stomach is still more deranged; there is a feeling of nausea and even vomiting on taking food. In the latter stages of phthisis, vomiting is also sometimes occasioned by violence of the cough, and the propagation of reflex actions, by means of the par vagum, to the stomach. In the former case, the sickness is to be alleviated by carefully avoiding all those substances which are likely to occasion a nauseating effect, by not overloading the stomach, but allowing it to have repose. In cases where too much medicine has been administered, a suspension of all medicaments for a few days will frequently enable the practitioner to introduce nourish- ment cautiously with the best effect. I have found the following mixture very effectual in checking the vomiting in phthisis : I£. Naphtha Medicinalis 3 j.; Tr. Cardamomi comp. 3 j ; Mist. Camphorce % vrj. M. ft. mist. Of which a sixth part may be taken every four hours. PHTHISIS PULMONALIS. 751 When it depends on the cough, those remedies advised for that symptom should be given. I have tried emetics for the relief of nausea and vomiting, but with no good result. Diarrhoea.—This is a very common symptom throughout the whole progress of phthisis, at first depending on the excess of acidity in the alimentary canal, to which we have alluded, but in advanced cases con- nected with tubercular deposits and ulceration in the intestinal gland. The best method of checking this troublesome symptom is by improving the quality and amount of the food. The moment the digestive pro- cesses are renovated, this, with the other functional derangements of the alimentary canal, will disappear. Hence at an early period we should avoid large doses of opium, gallic acid, tannin, and other powerful astringents, and depend upon the mildest remedies of this class, such as chalk with aromatic confection, or an antacid, such as a few grains of carbonate of potash. When, on the other hand, in advanced phthisis, continued diarrhoea appears, and is obstinate under such treat- ment, then it may be presumed that tubercular disease of the intestine is present, and the stronger astringents with opium may be given as palliatives. Haemoptysis.—This symptom sometimes appears suddenly in indivi- duals in whom there has been no previous suspicion of phthisis, and in whom, on careful examination, no physical signs of the disease can be detected. On other occasions, the sputum may be more or less streaked with blood; and lastly, it may occur in the advanced stage of the dis- ease, apparently from ulceration of a tolerably large vessel. In all these cases the best remedy is perfect quietude, and avoidance of every kind of excitement, bodily and mental. Astringents have been recommended, " especially acetate of lead and opium; but how these remedies can operate, I am at a loss to understand; and I have never seen a case in which their administration was unequivocally useful. I have now met with several cases where supposed pulmonary haemorrhage really origi- nated in follicular disease of the pharynx or larynx, and with the sup- posed phthisical symptoms, was removed by the use of the probang and nitrate of silver solution. Sweating I regard as a symptom of weakness, and therefore as a com- mon, though by no means a special one in phthisis. Here, again, the truly curative treatment will consist in renovating the nutritive pro- cesses, and adding strength to the economy. It will always be observed that, if cod-liver oil and good diet produce their beneficial effect, the sweating, together with the cough and expectoration, ceases. On the other hand, giving acid drops to relieve this symptom, as is the common practice, by adding to the already acid state of the alimentary canal, is directly opposed to the digestion of the fatty principles, which require assimilation. It should not be forgotten that consumptive patients, and all those suffering from pulmonary diseases, are especially sensitive to cold. The impeded transpiration from the lungs in such cases, is counterbalanced by increased action of the skin, which becomes unusually liable to the influence of diminished temperature. Again, cold applied to the surface immediately produces, by reflex action, spasmodic cough and excitation 752 DISEASES OF THE RESPIRATORY SYSTEM. of the lungs. Every observant person must have noticed how cough is induced by crossing a lobby, going out into the open air, a draught of wind entering the room, getting into a cold bed, etc. etc. The mere exposure of the face to the air on a cold day, takes away the breath, induces cough, and obliges the patient instinctively to muffle up the mouth. The numerous precautions, therefore, that ought to be taken by the phthisical individual, should be pointed out, especially the necessity of warm clothing, to which large additions should be made on going out into the air. Thus, covering the lower part of the face is important as a means of extra clothing, and not as a means of breathing warm air, as the favorers of respirators imagine. The patient should always sit with his back to the horse or to a steam-engine, and if by accident his shoes or clothes become wet, they should be changed as soon as possible. In the house, ladies should have a shawl near them, to put on in going from one room to another, in descending a stair to dinner, etc. By at- tention to these minutiae, much suffering and cough may be avoided. Febrile Symptoms.—The quick pulse, general excitement, loss of appetite, and thirst, which are so common in the progress of phthisical cases, are dependent on the same causes as those which induce sympto- matic fever in general. Vascular distention, resulting in exudation and its absorption, is proceeding with greater or less intensity in the lungs, and frequently in other organs. This leads to nervous irritation and increase of fibrin in the blood, accompanied by febrile phenomena. The intensity of these is always in proportion to the activity ot local disease, or to the amount of secondary absorption going on from the tissues, or from morbid deposits. Nothing is more common than attacks of so- called local inflammations in phthisis, and the careful physician may often determine by physical signs the supervention of pleurisy, pneu- monia, or bronchitis, on the previously observed lesion, and not unfre- quently laryngitis, enteritis, or other disorders. In such cases, nature herself dictates that the analeptic treatment, otherwise appropriate, is no longer applicable—food disgusts, and fluids are eagerly demanded. Under these circumstances, it has been common to apply leeches to the inflamed part, and extract blood by cupping, measures which undoubtedly cause temporary relief, but which are wholly opposed to the plan of gen- eral treatment formerly recommended, and to what we know of the patho- logy of the disease. Every attack of febrile excitement is followed by a corresponding collapse, and it should never be forgotten that, in a dis- ease which is essentially one of weakness, the patient's strength should be husbanded as much as possible. Hence the treatment I depend on in such circumstances consists of at first the internal administration of the neutral salts, especially of tartar emetic in small doses, combined with diuretics, in order to favor crisis by the urine. Subsequently quinine is undoubtedly advantageous. I have satisfied myself that such attacks are not to be cut short by leeches or cupping, and although in many cases, as previously stated, temporary relief is produced, the ex- posure of the person, and unpleasant character of the applications, the trickling of blood, and wet sponges, as often irritate, and give rise to unnecessary risk. Still there are cases where topical blood-letting, if it cannot be shown to have advanced the cure, cannot be proved to have PHTHISIS PULMONALIS. 753 done harm; but these cases, as far as my observation goes, are very few in number. ^ In the rapidly febrile cases, or the so-called instances of acute phthisis, mercury has been recommended ; but I have never seeta it produce the slightest benefit. Debility.—This is a very common symptom of phthisis from the first, and frequently leads the patient into indolence both of mind and body, a condition very unfavorable for the nutritive functions, upon the successful accomplishment of which its removal depends. It is to remove the weakness that tonics have been administered, but I have never seen quinine, bitter infusions, or even chalybeates, of much service alone, while the continual use of nauseous medicine disgusts the patient, and interferes with the functions of the stomach. Here again the great indication is to remove the dyspeptic symptoms, give cod-liver oil, an animal diet, and improve the appetite by gentle exercise and change of scene. Should the practitioner succeed in renovating the nutritive functions, it is often surprising how the strength increases, in itself a sufficient proof as to what ought to be the method of removing the debility. I have frequently seen patients who have been so weak that they could not sit up in bed without assistance, so strengthened by the analeptic treatment, that they have subsequently walked about and taken horse-exercise without fatigue, and this after all the vegetable, mineral, and acid tonics had been tried in vain. Despondency and Anxiety.—It is impossible for the careful practitioner to avoid noticing the injurious influence of depressing mental emotions on the progress of phthisis. Indeed the worst cases are those of indi- viduals with mild, placid, and unimpassioned characters, who give way to the feelings of languor and debility which oppress them. Such per- sons are most amiable patients—they give no trouble—anything will do for them—they resign themselves to circumstances, and state that they are eating well and getting better up to the last. These are cases of bad augury, for it is exceedingly difficult to inspire them with sufficient energy to take exercise, or to carry out those regulations which are abso- lutely essential to renovate the appetite and the nutritive functions. Such persons are benefited by slow travelling, cheerful society, and everything that can elevate the spirits, and, insensibly to themselves, communicate a stimulant to the mental and bodily powers. Anxiety, on the other hand, though it may sometimes depress and interfere with the digestive functions, is often a most useful adjunct to the physician. Those who experience it are most careful of their health, sometimes indeed too much so, but if once satisfied of the benefit of any particular line of treatment, they pursue it with energy. These are cases of good augury, and most of the permanent cures I have witnessed have been in such persons—medical men, and others acquainted with the nature of their disease, who have exhibited resolution, and a noble fortitude, and have bravely struggled against local pain, general debility, and nervous fear.* * For numerous other facts and observations connected with the pathology and treatment of phthisis, see the Author's work on Pulmonary Consumption, 8vo, 2d edition. Edinburgh. 48 754 DISEASES OF THE RESPIRATORY SYSTEM. CANCEK OF THE LUNG. Case CLXIIL*—Cancer of the Lung, Thyroid Body, and Lymphatic Glands of the Neck—Bronchitis—Leucocythemia. History.—Margaret Stewart, a cook, set. 60—admitted into the clinical ward July 16, 1851. For some years back she has been subject to a short dry cough, which has never been troublesome except after cooking a larger dinner than usual. With the exception of an attack of diarrhoea when the cholera was prevalent, she has been more or less constipated. Has never suffered from epistaxis or other form of haemorrhage. Four weeks ago she first perceived a swelling in the neck, which, com- mencing in front, has gradually spread towards the right side. Latterly her breathing has become short and hurried; her strength has decreased ; and the cough has been accompanied by considerable expectoration. Symptoms on Admission.—On admission, the neck presents a prominent indurated swelling anteriorly, measuring about four inches in diameter, evidently owing to en- largement of the thyroid body. A chain of enlarged glands extends from the anterior swelling round the right side of the neck, a little beyond the ear. She complains of great weakness, constant sweating at night, and cough with copious frothy expectora- tion. The chest is everywhere resonant on percussion. There are loud sonorous and moist rales heard over the whole chest, especially posteriorly and inferiorly. The vocal resonance is also unusually loud, but equal on both sides. The tongue is furred, dark brown in the centre; deglutition is difficult, apparently from pressure of the enlarged cervical glands. The appetite is bad, with an acid taste in the mouth. Other functions properly performed. Progress op the Case.—She continued in this condition for several days, during which iodine and counter-irritants were applied to the neck, and expectorants and antispasmodics taken internally to relieve the cough. The dyspncea, however, gradually increased; deglutition became more difficult, and her strength diminished. On the 30th of July the urine was ascertained to contain albumen, which had previously not existed. She died without a struggle, August 5th. Sectio Cadaveris.—Forty hours after Death. Neck.—On dissecting the integuments from the neck on the right side, a con- siderable number of glands, about the size of a barley-corn and small pea, were observed in clusters between the platysma myoides and sterno-mastoid muscle. A hard tumor existed in front of the neck, stretching along the whole front of the trachea, and over the great vessels on either side beneath the sterno-mastoid muscles, and posteriorly on the right side, as far back as the transverse processes of the ver- tebra?, and down beneath the clavicle to the anterior surface of the first rib, whore it was firmly adherent to the periosteum. A prolongation of the tumor, about the size of two walnuts, passed beneath the sternum at its upper end, being attached to its periosteum. This prolongation on section presented the outline of a congeries of enlarged lymphatic glands, having a white appearance, in some places soft, and even diffluent, and yielding on pressure a copious milky cancerous juice. Thorax.—There were lax adhesions at various points on the pleuise on both side?. The pleural cavities contained a little fluid on the right side, amounting to about five ounces. At the lower part of the left lung, and also at the back part of right lun4n the hypogastrium and right lumbar region, of a dragging character; he has also pain in the point of the penis during and after micturition; tongue moist and florid; he complains of sore throat, and on examination the tonsils are seen to be enlarged and covered with pus. He has tenderness of the epigastrium, and is troubled with vomiting immediately after taking food. Bowels regular. On percussing the chest, dulness can be detected at the apex of the right lung, anteriorly and posteriorly; on auscultation there is slight sibilation under the right clavicle, with slight increase of the vocal resonance. He has a slight cough, but no expectoration; pulse 88, and of good strength. Cardiac sounds feeble; heard loudest over the sternum, and a little to its right side; otherwise they are healthy. R Infus. Lini lbj. To be taken ad libitum. Throat to be sponged with a solution of nitrate of silver. Good diet. Progress of the Case.—July 25th.—The sponge has been three times applied to the throat, and it is nearly well. The pain has left the hypogastric region, and he has now a feeling of weakness in the right lumbar region. Urine of a milky color, contains less albumen, sp. gr. 1007. % Tinct. Iodinei 3 i. To be painted over the lumbar region. R Decoct. Uvaz Ursi lbj. One ounce to be taken four times a-day. August 8th.—During last week he has been suffering from nausea, vomiting, and looseness of bowels. Aug. 12th.—These few days past he has had rigors, followed by heat of skin and sweating. The attacks last only for a couple of hours, and come on regularly at two o'clock. He has been ordered the following pills:—5 Sulph. Quinm 3 ss ; Conf. Rosar. quant, suff. ft. massa in pilul. xx. dividenda. Two to be taken every sixth hour during the intermissions. Diarrhoea has continued, and for it he has been using the following mixture:— R Tinct. Catechu 3 vi; Sol. Mur. Morph 3 ij ; Conf. Aromat. 3 i; Mist. Gretas § v. M. One table-spoonful to be taken three times a-day. Aug. 14th.—Diarrhoea relieved; urine less turbid; sp. gr. 1009; not coagulable by heat and nitric acid. Aug. 21st.—Since last report has been gradually growing weaker. Mucous rale has been occasionally audible under the right clavicle; expectoration insignificant. He has been unable to retain any food on his stomach for several days, scarcely even wine and water. Diarrhoea has also returned. Latterly his strength has become very much exhausted, and during the last two days he has lain in a state of great prostration; his pulse often scarcely to be felt at the wrist; his intellect, however, never became impaired. This morning he died at four o'clock. Sectio Cadaveris.—Fifty-eight hours after death. Body much emaciated; rigor mortis considerable. Thorax.—Pericardium normal; contained about three drachms of clear straw- colored serum. Heart small and soft; valves healthy; muscular substance pale; under the microscope, the muscular fibres appear deficient in striae, and loaded with small fatty granules. Left pleura normal. Right pleura presents dense adhesions over the whole of the lung, more marked, however, at the apex and base. The right lung itself was small, collapsed, and excessively emphysematous along its an- terior free margin. The apex presented numerous hard cicatrices, and on being cut into, showed numerous tubercular masses in all stages, some of them commencing to break down and disintegrate, others undergoing the process of hardening and repair. In one spot, about an inch below the apex, a small vomica, about the size of a hazel nut, existed. Left lung voluminous; highly emphysematous; cicatrized around the apex, the cicatrices, as in the other lung, being very firm and dense. On being cut into, masses of tubercular matter were found, but in a more latent state than in right lung. Abdomen.—Liver normal in size, undergoing the fatty degeneration; pale- colored and friable; under the microscope, the hepatic cells appeared loaded with fat. Spleen normal. Small intestines healthy, slightly congested towards the lower part. Large intestines. The mucous membrane, throughout the whole extent, but particularly in the descending colon, sigmoid flexure, and rectum, appeared thickened, congested, and in many places ulcerated; the ulcers were small, their edges very slightly elevated, and their surface undergoing the process of separation. NEPHRITIS AND PYEIJTIS. 795 Right kidney was much enlarged; quite smooth ; the capsule densely adherent. On dividing the ureter, pus escaped in considerable quantity from the pelvis of the kidney; and on cutting into the substance of the gland itself, several ulcers, varying in size from a horse-bean to that of a small walnut, were found; their contents varied in consistence; in some, the pus was thin and diffluent; in others, it had the consistence and appearance of white paint. The ureter on this side was greatly thickened, of the size of an ordinary little finger; the thickening extended beyond the orifice of the ureter along the trigone of the bladder; the ureter was quite per- vious, and contained a quantity of pus. Left kidney was small and lobulated; the substance of the gland was found to have disappeared, leaving a large cavity, which was enclosed by a covering of the proper substance of the kidney, not exceeding four lines in thickness, and filled with cheesy matter of the consistence of putty; the ureter was closed, except for two inches above the bladder; externally, it was of normal size; muscular wall of bladder somewhat thickened, especially around the orifice of the right ureter; mucous coat congested and much softened; the bladder contained about 6 oz. of thick, turbid, semi-purulent matter. Commentary.—In this case, the renal abscesses formed in a young man of scrofulous constitution, and exhibited a more lingering tendency than in the former one. Indeed, notwithstanding the great disorganiza- tion found in the kidneys after death, the fatal result was chiefly brought about by the intestinal disease, and the exhaustion caused by colliquative diarrhoea. The left kidney evidently presented the incipient changes which commonly precede the spontaneous cure of scrofulous abscesses in this, as in other internal organs. The purulent matter presented the consistence of putty, the animal portion having for the most part been broken down and absorbed, while the mineral portion was comparatively increased. In this manner, not unfrequently encysted cretaceous masses form in the kidney and remain latent, the rest of the renal substance performing its normal function. Sometimes an entire kidney may, in this manner, be completely destroyed, and the whole converted into a calcareous mass, of which I possess a remarkable example, from an indi- vidual who had quite recovered from the disease, and whose remaining kidney, though enlarged, was in its texture healthy. Indeed, the sponta- neous cure of tubercular depositions in the kidney, presents the same pathological history as that we have described of similar lesions occurring in the lungs, p. 738, and the puckerings, cicatrices, cretaceous and calca- reous concretions resulting from them, have a similar significance. It follows that our general principles of treatment should also be the same, namely, supporting the constitution by analeptics and especially by cod- liver oil, so as to enable nature to bring about a cure. This ought always to be the primary object of treatment; whilst remedies directed to the renal symptoms should, although by no means neglected, be subordinate to that great end. In the present case this indication could not be ful- filled on account of the great irritability of the alimentary canal, especially of the stomach. For another example of this disease, see Case CLX. Case CLXXVIL*—Calculous Nephritis and Gangrenous Abscess of Right Kidney— Waxy Liver—Recto- Vesical Fistula. History.—James Allan, set. 25, a tin and copper smith—admitted August 18, 1848. At three years of age was cut for stone by Mr. Liston. Thereafter he enjoyed good health until three years ago, when, after straining himself at a trial of strength, he was suddenly seized with a sharp pain in the right flank, just below the ribs. At the same time the urine became turbid, and was of a high color. The pain left him at the end of three months, but the turbidity of the urine continued. After six months' interval he had a similar attack—this time, he says, induced by drinking a * Reported by Mr. Frederick Hunter, Clinical Clerk. 796 DISEASES OF THE GENITO-URINARY SYSTEM. glass of sphits—which also lasted three months. After another interval of about sij months, the pain and urinary symptoms again returned, and have continued more or less severe ever since. He was in the surgical hospital for three months, where he was frequently examined for stone, but none was found. At this time he was observed on several occasions to pass air by the urethra, the urine being of a gangrenous odor. He left the surgical hospital last May, and has been somewhat better since, the urine for some time having been clear and healthy. But having bathed in the sea a fort- night ago, he was seized with rigors, followed by fever, together with the former local symptoms, which have continued ever since. Symptoms on Admission.—The countenance is pale and sallow, expression de- jected ; body not emaciated, but with a general look of chronic disease. He com- plains of great pain and tenderness in the right lumbar region, which on examination presents a fulness, without great deformity, but well marked when compared with the opposite side. The hepatic dulness on percussion measures five inches vertically, the lower margin anteriorly being on a line with the umbilicus, and stretching across the abdomen into left hypochondrium. He has never suffered from pains shooting down to the bladder, nor in the bladder itself. But there is occasional pain after micturition, and always frequent desire to pass urine—indeed every hour—although little is voided. The urine is turbid, of dirty yellow color; acid, of sp. gr. 1017, very foetid, highly coagulable, and contains a considerable sediment of pus and mucus. The pulse is 108, soft. Tongue covered with a whitish fur. Appetite good. Other functions well performed. R Tart. Antim. gr. ij ; Aquw § viij ; Solve. Sumat § ss tertid quaque hord. Applicent. hirudines viii. lateri dolenti, el postea foveatur. Progress op the Case.—September 26th.—The local pain has been relieved by the treatment, but it returns with severity at intervals. For some time the urine has been clear. He has had a slight diarrhoea, which has been checked by a chalk and aromatic mixture; and has occasionally taken at night Pulv. Doveri gr. viij. October 3d.—Two days ago was again seized with rigors, fever, and acute pains in the right flank. The urine is again loaded with pus and mucus, and of foetid odor. The appetite is gone; there is thirst and frequent vomiting. Pulse 120, soft. A saline antimonial mixture. Oct. 6th.—Anxious countenance; pain continues, preventing sleep. Can take no nourishment. Much exhausted. Vomiting diminished. R Pulv. Doveri gr. x. hora somni. Nutrients. Wine four ounces daily. Warm fomentations to the side. Oct. 10th.—Local pain somewhat diminished. Complains of diarrhoea. R Acid. Gallic. 3 ss ; Opii, gr. xij; Conf. Rosar. q. s. ; ft. pil. xij. Sumat unam sextd qudque hord. Oct. 15th.—Since last report has gradually sunk, and died this morning. Sectio Cadaveris.—Forty-eight hours after death. Thorax.—Pericardium contained about a drachm of turbid serum, with a few floating flakes of lymph. Lungs and heart healthy. Abdomen.—The liver was considerably enlarged, and had undergone the waxy degeneration; its substance being pale and dense, with a smooth surface on section. On attempting to remove it, the right lobe was found to be adherent to the colon ; and on separating this adhesion with the fingers, a quantity of pus escaped. This originated from a large abscess in the right kidney, containing about half a pint of pus, mixed with curdy matter. The superior wall was composed of the substance of the liver, a portion of the lower and posterior border of which organ was absorbed. The posterior wall rested on the quadratus lumborum muscle, and anteriorly it was in contact with the transverse colon and the pyloric end of the stomach. When opened from behind, the walls of the abscess were found to be covered with shreds of gangrenous tissue, of a dark greenish color, of gangrenous odor. Renal substance could only be detected at the lower part; the rest of the kidney was converted into a fibro-cystic structure, in some places of great density. Two of the cysts contained uric acid calculi; one resembling in size and form two walnuts united together by a neck, the other of a somewhat angular form, with rounded edges, the size of a hazel nut. These calculi were embedded in pus, and partly projected into what might have been the pelvis of the kidney, but which was converted into a fibrous sac communi- cating with the ureter. The bladder presented at its neck the cicatrix of an incision made in the usual situation for lithotomy. About two inches above this were three mucous excrescences the size of peas. In the centre of these was a depressed spot, •through which a director readily passed backwards and upwards through the cellular tissue into the rectum. The mucous surface of the rectum at this point was highly vascular, and covered with lymph in patches to the extent of four inches in depth NEPHRITIS AND PYELITIS. 797 round the gut. Left kidney weighed 13£ oz., and appeared healthy in structure. Other organs normal. Microscopic Examination.—The structure of the left kidney was quite natural. The liver presented the usual atrophied and translucent appearance in the cells, characteristic of the waxy degeneration, a few only containing a small number of fat granules. Commentary.—The local and general symptoms in this case were so clear, as to leare me in no doubt from the first that this man had a calculus embedded in his right kidney, causing an abscess in that organ. The recurring rigors and fever, with pains shooting down the right groin to the bladder, and occasional vomiting; the turbid, bloody, purulent, and gangrenous urine; the remarkable fulness in the right lumbar region, with tenderness on pressure; and tha past history of the case, constituted an unmistakable group of phenomena diagnostic of calculous nephritis. Indeed, so certain was the fact, that more than once nephro- tomy was spoken of as a possible means of relieving him, every other organ1 with the exception of the liver being at one time apparently healthy. It was with great interest, therefore, that the dissection after death was watched, which fully confirmed the diagnosis. It also pointed out that the other kidney was enlarged and healthy, performing double duty without difficulty; that the liver was enlarged and waxy, and that a recto-vesical fistula existed, causing disease of the intestinal mucous membrane, to which the diarrhoea latterly might be attributed. In reference to an operation, it appeared to me at the time that it might easily have been effected after the method of Marchetti,* as the two calculi were loose within cysts, and surrounded bv pus. The enlarge- ment of the liver prevented the performance of sucn an operation being seriously entertained in this case. But here, as in ovariotomy, the great difficulty is to establish in the living subject an exact diagnosis, and this I had no difficulty in doing six weeks before his death, and when his general health was tolerably good. For such a disease nothing but palliatives are to be thought of. As the size of the stone cannot be known, diluents are indicated with the possibility of favoring its descent along the ureters to the bladder, a practice which, should it fail in that respect, is also useful in carrying off the pus which may accumulate in the pelvis of the kidney, should perchance any healthy secreting texture still remain in it. Case CLXXVIII.f—Chronic Pyelitis, and Cystic Kidneys—Dilatation of Ureters—Fungoid Ulceration of Urinary Bladder. History.—Jane Watson, aet. 74, widow—admitted November 15th, 1852. As far as can be ascertained from the patient, whose mental faculties are very much impaired, she has been laboring under her present complaint for the last eight months. About that time she was exposed to cold from sleeping on damp straw, and was seized with rigors, pain in the back, and in the larger joints. The urine at the same time de- creased considerably in quantity, with frequent micturition, accompanied by pain. These symptoms lasted for about a month, after which the amount of water passed be- came greatly increased in quantity, and dysuria disappeared. For the last three months, the urine has been occasionally mixed with blood, continuing for a few days, * An account of a gentleman being cut for the stone in the kidney, with a brief inquiry into the antiquity and practice of nephrotomy, by C. Bernard.—Phil. Trans., October 1696. f Reported by Mr. Robert Francis M. Russell, Clinical Clerk. 798 DISEASES OF THE GENTTO-URINARY SYSTEM. and then becoming natural. Since the date of her first attack, she has complained of pain in the region of the right kidney, much increased at those periods when blood waa observed in the urine. Symptoms on Admission.—On admission, she has a peculiar cachectic appearance, and is much emaciated. Tongue moist, cracked in the centre, great thirst, appetite impaired, bowels costive. She has considerable pain and tenderness on pressure in the right lumbar region, where there is also some fulness. The urine is passed in consid- erable quantity, specific gravity 1010, alkaline, highly coagulable on the addition of heat and nitric acid. It is quite turbid when passed, and deposits on standing a copi- ous yellowish gelatinous-like sediment, which, under the microscope, is seen to contain numerous pus corpuscles, granule cells, and casts of the tubes, crowded with gran- ules. When the bladder is about half empty, there is frequently a sudden stoppage of the flow of urine, when she suffers from severe pain in the hypogastrium, stretching down the thighs, especially on the right side. Pulse 90, of moderate strength. Heart's sounds feeble, otherwise normal. Other functions natural. The bladder was examined by Mr. Syme, and a large ulcer was detected, occupying the base and neck of the bladder. R Tinct. Hyoscyami 3 vi; Tinct. Opii 3 ij ; Mucilaginis et Aquoe aa. 3 vi. Sumat § j ter indies. Progress of the Case.—November 18th.—Continues much in the same state. Urine presents the same characters as before. Omittatur mistura Hyoscyami. R Potasses Acetatis § ss ; Sp. A^theris Nitrici 3 iij ; Mucilaginis et Aqum aa 3 iij. M. Sumat 3 j quartd qudque hora. R Sol. Mur. Morphia; 3 j ; Mist. Camphora | j. M. Sumat dimidium hora somni et alterum post horas tres si opus sit. Warm fomentations to be applied to the loins. Nov. 21st.—The warm fomentations were applied as ordered, and afforded considerable relief; she sleeps well at night after tak- ing the draught; the casts have now disappeared from the urine, but a few granule cells are still visible, mixed with pus corpuscles, blood globules, and some crystals of triple phosphate. Urine still of specific gravity 1010, highly albuminous, and of a very putrid smell immediately after being passed. Nov. 24th.—The quantity of urine is now greatly diminished ; presents the same characters as on the 21st. There are still pain and tenderness in yght lumbar region; frequent desire to pass water, the first half of which flows with comparative facility, but the remainder comes away slowly, requir- ing external pressure to empty the bladder, at the same time there are sharp shooting pains in the vulva, and the inner side of the thighs, extending down to the knees. She appears much exhausted ; pulse weak, 96. To have four ounces of wine. Nov. 28th. —Is much in the same state ; the urine is still highly coagulable ; the sediment exam- ined by the microscope presents a large number, 1st, of finely molecular exudation casts; 2dly, groups of broken down pus cells; 3dly, crystals of triple phosphate; 4thly, granular cells ; 5thly, blood corpuscles. December 4th.—Is now passing her faeces and urine involuntarily; appetite rather improved; pulse, 85, weak. The warm fomenta- tions have been continued since the 18th ult. To have six ounces of wine. Dec. 8th. —Still passes everything in bed ; complains of great pain and tenderness in right lum- bar region ; still takes food well; pulse 90, of better strength. Dec. 15th—Appetite very much impaired within the last two or three days; still complains of pain over right kidney, and passes dejections involuntarily. Only an ounce of urine could be obtained for examination. It is still coagulable; the sediment presenting, under the microscope, the same characters as on the 28th ult., with an increase in the number of blood corpuscles; pulse 100, very weak. Dec. 23d.—Since last report the patient has been gradually sinking, and she died this morning. Sectio Cadaveris.—Fifty hours after death. Body emaciated. Thorax.—Pericardium contains about two ounces of serum. Heart small, presents a large amount of fat on its surface; valves and endocardium perfectly normal. Left lung slightly adherent at apex; middle and lower lobes of right lung strongly adherent posteriorly; both lungs were crepitant throughout, with the exception of some hard- ened deposits at apex of the left, which look like old tubercle. Bronchi contain much frothy mucus. The aorta through the whole of its course (and both iliac arteries) con- tained a large amount of calcareous deposit, principally seated in the arch of the aorta, and the thoracic portion of that vessel. Abdomen.—Stomach and intestinal canal normal; pancreas pale: spleen very small; liver small, congested, firm, and dense. Lumbar glands considerably enlarged, NEPHRITIS AND PYELITIS. 79S ind contain a very great amount of yellowish opaque juice, evidently purulent, but no distinct abscesses. Both kidneys of normal size when viewed externally; the ureters dilated to the size of swan quills ; pelvis of both kidneys dilated to three or four times the normal size; cortical and tubular substance correspondingly small in volume; several of the pyramids distorted and crooked in direction, but their basic line al- ways distinct; cortical substance pale ; malpighian bodies and striae destitute of blood ; surface smooth, but more adherent to capsule than usual. On careful examination with the naked eye, a considerable number of cysts from the smallest visible size up to t inch diameter are observed in the cortical substance, especially near the surface. The bladder of normal size; all its walls much thickened; the mucous membrane presents a soft fuugoid-looking ulcerated mass, in which no peculiar or character- istic structure could be observed. All parts of the mucous membrane were equally diseased. Microscopic Examination.—The cysts in the kidney can be traced down to very minute sizes (the smallest observed was about the 600th of an inch in diameter), having the usual appearance of such cyst formations. The malpighian bodies shrunk, bloodless and opaque, without apparent morbid deposit, but with thickening of their membrane and nuclei. In some of the tubes similar thickening and epithelial engorge- ment, producing an appearance of opacity in the tubuli without any recognisable gran- ular deposit. When the tubes are washed out and examined separately, they appear (most of them) smooth. Epithelium small and compressed, but, generally, regularly disposed and normally developed. In a few places, traces of granular and molecular exudation, but to an insignificant extent. Commentary.—The complication of renal and vesical disease here met with, is by no means an uncommon one in aged persons. Its existence leads to obstruction of the ureter, at its entrance into the bladder, disten- tion of the ureter above, accumulation of urine in the pelvis of the kidney, and, as a consequence, inflammation and distention of its mucous lining walls, pressure on the secreting portion, and atrophy of its substance. Such a lesion, if it exist in both kidneys, must necessarily at last so inter- fere with their functions, as to be incompatible with life. The chronic disease of the bladder, on which the renal disea.se for the most part de- pends, only admits of palliative measures for its relief. Cystic disease of the kidney may originate in various ways,—1st,'From greater or less obstruction in the tubuli uriniferi, and consequent accumu- lation of the fluid above, forming cystic collections. 2d, It may originate in the sacs surrounding the malpighian bodies, the fluid accumulating in them producing distention, and so causing cysts. 3d, In the enlarge- ment of the secreting cells of the organ, which here, as in the ovary, be- come distended with fluid, and by pressing upon, compress one another. 1. The obstructions found in the tubuli uriniferi are of various kinds, and may consist of coagulated exudation, of pus, of blood, of altered epi- thelium cells, or of different salts, such as urates, carbonates, phosphates, etc. etc. The bloody points so frequently observed on the surface of diseased kidneys, most frequently arise from extravasation of blood into the convoluted extremities of the tubes. Small calculi may be formed from mineral deposits, but more commonly the tubular cones present a diffused white appearance from their occurrence. That such a condition is a frequent source of cysts, may be easily proved by examination. The cysts so formed may be of different sizes, varying from that of a millet seed to that of an orange, and the destruction of the secreting portion of the kidney will, of course, be proportionate to their volume and number. The contents of such cysts are also of various kinds, such as serum, blood, 800 DISEASES OF THE GENITO-UR1NAET SYSTEM. pus, fibrous exudation, colloid and fatty matter, fluid holding various crystals in suspension, whether fatty (cholesterine or margarine), or saline (phosphates, urates, etc.). I have frequently seen all the forms in the following figure (Fig. 474), and occasionally the radiated bodies repre- sented Fig. 321. 2. That numerous cysts may form from distention of the minute sacs surrounding the malpighian body, I have satisfied myself of by careful examination, and possess preparations demonstrating the fact. In this case, the cysts are generally numerous and scattered through the cortical substance. It would appear to arise from some obstruction at the com- mencement of the excreting duct, although I have never been able to detect any. Fluid collects outside the membrane in immediate con- tact with the tuft of vessels constituting the malpighian body, and inside another membrane continuous with the basement membrane of the latter. Indeed, it is in cases of this kind that we.may satisfy ourselves that the Fig. 474. membrane investing the tuft of vessels is really double, forming a shut serous sac, in the cavity of which the fluid accumulates. This fluid is invariably clear, various in quantity, but each cyst seldom exceeds a small pea in size. As it forms, it gradually presses on the vascular tuft, and causes its atrophy, and so impedes the secretory power of the organ. 3. The third form of cystic formation in the kidney evidently ori- ginates in the secreting cells themselves, as thfey may be seen, on a microscopic examination, to exist in clusters, varying in size from the 600th to the 16th of an inch in diameter. In such a case, the paren- chyma of the organ seems to be infiltrated with them, and strongly reminds the observer of a section of the ovary, loaded with Graafian vesicles. Many still retain their nucleus, whilst in others it has disap- peared. Mr. Simon of London, who first described this form of cystic Fig. 474. Structures occasionally seen in cysts of the kidney; a and b, Structure- less transparent colloid masses; c to g, Colloid bodies, composed of one or more nuclei, imbedded in albuminous matter; h to i, Colloid masses, surrounded by con- centric laminae; k, A colloid mass, with fatty granules arranged in an areolar manner. —{Wedl.) 350 diam. BRIGHT'S DISEASE. 801 formation, says, as explanatory of its formation, " that certain diseases of the kidney (whereof subacute inflammation is by far the most fre- quent) tend to produce a blocking of the tubes ; that this obstruction, directly or indirectly, produces rupture of the limitary membrane ; and that then, what should have been the intra-tubular cell-growth, continues, with certain modifications, as a parenchytic development." * One or all of these forms of cystic growth in the kidney may be as- sociated with the next lesion to be treated of, viz., Bright's disease. PERSISTENT ALBUMINURIA, OR BRIGHT'S DISEASE. That albumen in urine was a symptom of certain dropsies, was first noticed by Dr. Wells of St. Thomas's Hospital,! and Dr. Blackhall of Exeter; that it indicated especially renal dropsies, was the discovery of Dr. Bright, who has given us a careful account of the phenomena which characterise the disease that has since borne his name, as well as of the changes observed in the kidney after death. The subsequent observa- tions of Christison, Martin, Solon, Rayer, and others, as well as the more recent investigations of Gluge, Johnson, Simon, Frierichs, and others, have rendered it certain that the lesions of the kidney accom- panying albuminuria are various. Some are dependent on what may be considered an acute or chronic form of inflammation (see Nephritis), whilst others must be referred to what we now call the fatty and waxy degenerations. In selecting the following cases as illustrative of the disease, I have kept in view its natural progress, and endeavored to show how, by judicious treatment, it sometimes terminates in recovery ; how at other times it frequently becomes obstinate, and in what manner it may ultimately cause death. Of the pathology and treatment I shall speak separately, after describing the facts we have studied at the bedside. Case CLXXIX.if—Albuminuria—General Anasarca—Oedema of Lung— Recovery. History.—Elizabeth Brady, set. 30, cook, married—admitted March 19th, 1854. She states that her health was good until four weeks ago, when, after exposure to cold and wet, she was seized with pains in the chest, and cough, but without shivering. Three days afterwards her feet began to swell, and gradually the swelling extended upwards, involving her whole body. Symptoms on Admission.—On admission, chest well formed; breathing slightly labored. On percussion, unusual resonance is perceived over the upper portion of both sides anteriorly. There is a marked dulness on the left side below the nipple and lower angle of scapula. On applying the stethoscope over the portion marked as dull, fine crepitation is perceived. Elsewhere on the left side, the inspiration is harsh and the expiration prolonged; pulse 100, small and hard; cardiac sounds normal; tongue covered with a brown fur; complains of nausea and disinclination for food. The abdomen is distended with fluid, and she has pain in the epigastric region; bowels constipated; urine rather scanty, sp. gr. 1028, is turbid when voided, and on standing deposits a copious sediment, which, when placed under the micro- scope, presents chiefly amorphous urate of ammonia, with a few tube-casts. On the application of heat and nitric acid a large coagulum is thrown down. Catamenia regular. Her skin is hot; her face flushed and swollen; she suffers from general * Medico Chirurgical Transactions, vol. xxx. p. 152. f Trans, of a Society for promoting Medical and Surgical Knowledge, vol. iii. pp. 147, 167. % Reported by Mr. W. W. Clark, Clinical Clerk. 51 802 DISEASES OF THE GENITO-URINARY SYSTEM. anasarca ; lj er lower extremities, however, being especially affected, and pitting easilr on pressure. Progress of the Case.—March 21st.—Ordered to be bled at the arm to the extent of twelve ounces, R. Pulv. Doveri 3i. Tales vi. One to be taken at bed-time. March 22d.—Fifteen ounces of blood were withdrawn from the arm, and the pulse shortly fell to 70. She expressed herself as greatly relieved. After taking the Dover's powder she had a short sleep, but no diaphoresis was produced. The blood withdrawn presents no buffy coat; her urine is voided in larger quantity, but still deposits a considerable sediment; pulse 90, soft and weak. I£ Potass. Acet. 3i; Sp. A^th. Nit. 3 vi; Syrup. Aurantii § i; Aquce % iv. M. One ounce to be taken three times a day. fy Pulv. Gambogice gr. v ; Potass. Bitart. 3 ij. M. To be taken at bed-time. March 23d.—Her bowels have been well opened, and her general appearance is greatly improved, her face being much less swollen; urine less turbid, and in larger quantity. Intermittatur mist IJ Pil. Scillce et Digital, xii. One to be taken every sixth hour. March 24th.—Her cough has abated greatly, and she feels herself much better. Repetat. Pulv. Gamb. et Potass. Bitart. vespere. Match 26th.—Urine deposits very little sediment on standing; and, under the microscope, no tube casts can be detected: sp. gr. 1018. A slight coagulum is produced on applying heat and nitric acid. Her appetite is greatly improved. March 29th.— On examining her chest to-day, the dulness on percussion, which previously existed on the left side, cannot now be detected, and on auscultation over that portion the respiratory murmur is heard normal. Under the right clavicle the inspiration appears unusually harsh. Her urine presents the same character as at last report. Repetan- tur Pil. Scillm et Digital, et Pulv. Potass. Bitart. 3 ss ter indies. April 3d. She is now nearly convalescent, and has taken no medicine for two days. To have steak diet. May 8th.—Complains to-day of pain in the epigastrium and of vomiting; bowels constipated ; pulse natural; urine yields no coagulum to the usual re-agents; sp. gr. 1008 ; contains no tube-casts on microscopic examination. Menstruation rather frequent, and, in the intervals of the catamenial periods, she is subject to a leucorrhoeal discharge. B Naphthae Medicinal. 3 i; Tinct. Cardam. Co. § i; Aqum 3 v. M. A table-spoonful to be taken when the vomiting is troublesome. R Mag- nesia Carb. 3 ss ; Aq. Cinnam. § i; Infus. Sennm Co. 3 ij ; M. Ft. haust. hora somni sumendus. Intermittantur alia. July 20th.—Since last report her urine has remained entirely free of albumen. The oedema has now for the most part entirely disappeared, but still returns slightly after she has been for some time in the erect po- sition. General health good. Dismissed. Commentary.—On succeeding Dr. Christison in the charge of the clinical wards on the 1st of May 1854, I was informed that this was a case of Bright's disease. On the 8th of the month, however, as stated in the report, on examining her urine, I found it to contain no albumen on the addition of heat or nitric acid, while the sediment, carefully collected, exhibited no tube-casts under the microscope. On looking into the history of the case, as recorded in the ward-book, and which is given above, it became clear that the woman had undoubtedly been laboring under albuminuria and chronic renal disease, which, well pronounced March 21st, had entirely disappeared at the beginning of May. But the oedema of the feet continued, with stomaehic derange- ments ; the former symptom exhibiting a tendency to return, on assuming the erect position for any time; and in consequence, she was not dismissed until the 20th of July. Before saying anything with regard to the treatment, it will be well to attend to the facts exhibited by some other cases. Case CLXXX.'*—Albuminuria—(Edema of both feet and legs, left arm and hand—Recovery. History.—Robert Lindsay, set. 62, carder of wool—admitted 21st March 1854. * Reported by Mr. Robert Bird, Clinical Clerk. BRIGHT'S DISEASE. 803 States that, twenty-three years ago, he had a violent attack of rheumatism which laid him up for ten months. After his recovery, his health continued good, until ten years ago, when he began to suffer from symptoms of stone in the bladder. He underwent the operation of lithotomy, but made a tardy recovery, being unable to resume his work until upwards of twelve months afterwards, and for two or three years subsequently he was subject to attacks of rigors, which compelled him to keep within doors for several days at a time. He then became tolerable healthy, and con- tinued so until three weeks ago, when he noticed his left wrist somewhat swollen, and in the course of two days his lower extremities became likewise oedematous. He suf- fered from a dull heavy pain in the lumbar region, which has been present more or less ever since he underwent the operation ten years ago. His urine, at the time the swelling commenced, was scanty and high colored, and he was troubled with a slight cough. He says that about the time when his illness began, he was engaged in clean- ing machinery, and may have caught cold. He is not aware of any other cause which might have brought on his ailment. He acknowledges that formerly he was a free liver, but since the operation he has been very temperate. Symptoms on Admission.—On admission, both feet and legs are oedematous, pitting on pressure. There is also slight swelling of the left arm and hand. He complains of a dull pain in the lumbar region on both sides, but that on the left is most severe. Micturition frequent; he is obliged to rise several times in the course of the night for that purpose. It is not attended with pain or difficulty. Sp.gr. of urine 1011; co- agulable by heat and nitric acid. He complains of frontal headache. Sleeps badly, being much disturbed by dreams and sudden startings. Tongue moist and clean; complains of great thirst; appetite impaired ; bowels regular; has a slight cough, with very little expectoration; chest everywhere resonant on percussion. At the apices of both lungs anteriorly, and at the apex of the left posteriorly, sibilant rales are heard. He has suffered from palpitation for the last three weeks, but the cardiac sounds are normal. R Tinct. Ferri Mur. § i. Ten drops to be taken three times a-day. R Pulv. Doveri gr. x. Mittant. tales vi. One to be taken morning and night. Progress of the Case.—March 23d.—This morning he had violent vomiting, but it has now abated, and he complains of great thirst. March 26th.—Ordered pills of digitaline, each containing l-74th of a grain. One to be taken three times a-day. March 28th.—After taking the pills of digitaline twice, excessive purging came en; their further use was therefore abandoned. The urine was very slightly increased in quantity. April 4th.—The use of digitaline was resumed four days ago, and now the coagulability of the urine has entirely disappeared. The oedema of his lower extremi- ties has abated greatly. The purging, caused by the digitaline, was counteracted by opium pilli. May 3d.—Since last report the urine has been several times examined, and has been always found to be free of albumen. To-day only the slightest haze is caused by heat and nitric acid; the urine is pale colored; sp. gr. 1014, transparent, and without sediment on standing; 84 oz. are passed in the twenty-four hours. The oedema has not entirely disappeared from the feet and ankles. He continues to take the digitaline pills. His general health is much improved. May 11th.—Two days ago he was ordered the following:—R Tinct. Ferri Mur. % i. Fifteen drops to le taken thrice a-day. To-day he has passed 54 oz. of urine. The oedema of his feet and ankles is abating. A few minute flakes are produced on treating the urine by heat and nitric acid. May 13th.—78 oz. of urine were voided during the last 24 hours. R Sp. A^th. Nit. 1 iss ; Aq. Potass. ; Tinct. Digital, aa 3 ij. M. A tea- spoonful to be taken thrice a-day. Continue Tinct. Mur. Ferri. May 19th.—Amount of urine passed during the twenty-four hours is 100 oz. June 22d.—OZdema of legs almost entirely gone ; 68 oz. of urine passed during the last twenty-four hours; sp. gr. 1014; quite unaffected by heat and nitric acid. June 26th.—His feet and ankles are slightly oedematous at night; 60 oz. of urine passed during the last twenty-four hours; sp.gr. 1017. No coagulum produced by heat and nitric acid. Jidy 11th.— Dismissed quite well. Commentary.—In this case, also, we can have no doubt of the exist- ence of Bright's disease, although on my succeeding Dr. Christison in the clinical wards I found no albumen in the urine, and that the patient was rapidly recovering. Digitaline had been tried, with the effect of producing excessive purging, and slight increase of the uriuc. The 804 DISEASES OF THE GENITO-URINARY SYSTEM. albumen shortly afterwards disappeared from the fluid, but here, as in the last case, the cedema continued, and he subsequently became quite well. These two cases, therefore, indicate that purgatives and diuretics are sometimes very efficient in entirely removing the disease. Case CLXXXL*—Albuminuria—QHdema—Ascites and General Ana- sarca— Coma and Convulsions—Recovery. History.—Alexander Strachan, set. 36, a joiner—admitted October 25, 1858. Ho enjoyed good health up to the 2d October last, when, after exposure to cold and wet, he was seized with a rigor, followed by severe cough and slight expectoration. On the 6th he first remarked swelling of the lower extremities, and in the evening, on tryin» to make water, he, with some difficulty, passed about half a pint of brown, smoky- colored urine. On the following morning this presented a sediment of a light color and viscous consistence. He at this time suffered from constipation, and was ordered a dose of castor-oil by his medical attendant. On the 7th he had a copious evacuation from the bowels, but his legs continued to swell. On the 8th his water which was small in quantity, still presented a white, viscous sediment. The legs became more swollen, the abdomen now began to increase in size, and great difficulty of breathing came on. He continued in this state up till the day of his admission. Symptoms on Admission.—There is great oedema of both legs, ascites, and general anasarca. He has a good deal of cough and frothy expectoration; but, with the ex- ception of occasional fine moist rale and sibilation posteriorly, the lungs are healthy. Cardiac dulness and sounds normal. Pulse 70, of moderate strength. He complains of a dull pain over the region of the kidneys. Urine of a dark, smoky color, highly albuminous, and depositing a whitish, tenacious sediment. Tube-casts and blood cor- puscles are very abundant, as determined by the microscope. Other symptoms nor- mal. To be dry cupped over the kidneys, and to take 3 j doses of Pulv. Jalapm Comp. three times a day. Progress of the Case.—October 29th.—The cough and expectoration have greatly diminished since he came into the house, but little impression has been made upon the dropsy. November 2d.—Ordered Pil. Digitalis et Scillce xij ; one three times a-day, in addition to the powders. November 1th.—Has passed quantities of urine varying from 20 to 44 oz. daily, although generally it has been deficient in quantity. The dropsical symptoms have undergone no change. This morning at four o'clock he was seized with convulsions and loss of consciousness. Had three more fits at intervals during the day. Urine of a smoky tint, containing tube-casts and blood corpuscles. Ordered to be cupped to 5 ounces over the region of the kidneys. To have 3 j of the Bitartrate of Potass three times a-day. November 8th.—Had three fits to-day, and been drowsy. November 9th.—The drowsiness is nearly gone to-day, and he is quite sensible, though complaining of an intense headache. Pulse 108, of fair strength. Urine 40 oz., sp. gr. 1015, albuminous and containing blood corpuscles. Dropsy of the legs has nearly disappeared, and the abdomen feels softer. It measures 36 inches round the most prominent part. November 10th.—OZdema of legs entirely gone; not the slight- est pitting on pressure. Complains of seeing objects distorted, and sometimes of a haze which appears before his vision. He continues to take the Squill and Digitalis pill, one four times a-day, and 3 j doses of bitartrate of potash. November 11th.— Six dry cupping-glasses were applied over the lumbar region this evening. The pupil of the eye was observed to be considerably dilated. November 12th.—Passed 68 oz. of urine free from albumen. November 13th.—Passed 42 oz.; and November 14th, 46 oz. of urine. To-day the left pupil was observed to be contracted, the right dilated. Sees whatever object he has been looking at magnified on the opposite wall. Novem- ber 19th.—Since last report, has passed on the different days, 48, 60, 135,132, and 98 oz. of urine. To-day it shows a mere trace of albumen. Abdomen much less tense, measures 34 inches. From the 19th to the 27th has been passing about 90 oz. of urine daily. It has still a dim, smoky tint, reaction acid, sp. gr. 1018. Nitric acid imparts to it a red tint, and after boiling flakes of albumen appear. From this time he gradu- ally recovered. He was for some days troubled with muscse volitantes, but was dis- missed on the 1st of December at his own request, the dropsy having completely dis- appeared, and only the faintest trace of albumen existing in the urine. * Reported by Mr. George Shearer, Clinical Clerk. bright's disease. 805 Commentary.—hx this case the amount of general anasarca was very great, and_ purgatives and the squill and digitalis pill produced no effect, so that poisoning of the blood with urea caused coma and severe con- vulsions. These were of an epileptiform character, with foaming at the mouth, each paroxysm being of about ten minutes' duration. From this state the patient was roused by the energetic action of the bitartrate of potash, which, by increasing the flow of urine from the kidneys, rapidly diminished the head symptoms, and completely removed the dropsy. The following case, which is the most remarkable recovery I ever saw, still further points out the value of this drug in Bright's dis- ease of the kidneys. Case CLXXXIL*—Third Attack of General Anasarca with Albuminuria —Enormous Dropsical Distention of the Abdomen, Scrotum, and Inferior Extremities—Complete Recovery under the Action of Super- tartrate of Potash. History.—William Herdmann, set. 49, single, a lithographer—admitted March 81st, 1855. Patient admits that he has been a man of rather intemperate habits, al- though this has not been the case of late. Twelve years ago, without any premoni- tory symptoms, he was suddenly seized with general anasarca and with ascites. For this he entered the Infirmary, and after treatment was dismissed " Cured." Six years after the first, he suffered from another attack, which was also cured in the Infirmary. Within the last fortnight he has been again attacked by " dropsy," which has been gradually increasing. Symptoms on Admission.—On admission, the quantity of urine passed is small, but he is not obliged to rise during the night to pass his water.. No pain in the loins, or tenderness on pressure. Abdomen is considerably swollen, especially at the lower part. Circular measurement below umbilicus, 30£ inches. When he lies on his back, the anterior part of the abdomen is tympanitic, and the flanks dull on percus- sion. On turning him to either side, the one which is uppermost becomes clear on percussion, and the undermost remains dull. There is slight cedema of the ankles, but he notices, every morning, some puffiness in the cheeks, especially on the right side (that on which he usually lies). Bowels rather costive; appetite very bad; tongue foul, and covered with thick brown fur; considerable thirst; complains of cough and shortness of breath; expectorates a little frothy mucus. Percussion of chest anteri- orly resonant on both sides. On auscultation in front, there is heard on both sides harsh inspiration, attended with very prolonged expiration. Posteriorly, at both bases, there are loud sibilant and crepitating rales. Heart sounds indistinct; no mur- mur ; pulse 68, of good strength; sleeps well; has complained a little of drowsiness for the last few days; skin dry and harsh. Urine very scanty; has only passed 12 oz. since admission. The application of heat converts the whole quantity in the test- tube into a firm coagulum; sp. gr. 1024. Casts of tubes and oil globules are found in the sediment. Descendat in balneum calidum vespere. Sumat. Pil. Scilla et Digita- lis), ter in die. R Tr. Opii Ammoniatce ; Sp. Lavendulce Co. aa 3 ss ; Mist. Scillce | v. M. Sumat 3 j ter in die. Progress of the Case.—April 4th.—Has passed 16 oz. of urine during the last twenty-four hours. Swelling of abdomen increased; it measures below umbilicus 33 inches. He is very thirsty. April 5th.—Only 9 oz. of urine passed since last report; sp. gr. 1018 ; highly coagulable ; bowels costive; tongue dry and furred; cough still present, with expectoration of tough frothy mucus; sibilant and crepitating rales still heard at bases of both lungs posteriorly. Repeat the warm baths. Injiciatur enema foetidum. Habeat Pulv. Ipecac. Co. gr. x. hac node et repetatur eras mane. April 6th.—Obtained little relief from the injection; skin of chest, abdomen, and loins, pits upon pressure. Abdomen measures 34f inches in circumference ; passed only 9 oz. of mine since last report, of same character as before. Breath has a urinous odor. Continuent. Pil. Scillce et Digitalis et sumat Potass. Bitart. liter in die. Repetatw * Reported by Mr. Robert Byers, Clinical Clerk. 806 DISEASES OF THE GENITO-TJRINARY SYSTEM. Pulv. Doveri. April 15th.—Urine passed daily has been from 8 to 15 oz., of sp. gr, about 1020, and highly coagulable. Omittantur Pil. Scillce et Digitalis. To apply spongiopiline constantly to the abdomen, saturated with a strong solution of Infus. Digitalis. April 22d.—Urine not increased in quantity, varies from 9 to 15 oz. per diem; abdomen measures 37£ inches. The Inf. Digitalis has produced a rash of a papular character over the surface of the abdomen. R Sp. A^th. Nitrici 3 vj; Aq. Cinnamomi | vss. M. Habeat § j ter in die. April 25th.—Says that the last mix- ture has given him great relief; has passed 26 oz. of urine after it. The spongio- piline to be removed, owing to irritation which it has caused in the skin of abdomen. May 2d.—Base of left lung dull on percussion posteriorly; no rale; a good deal of pain in abdomen; bowels costive; skin dry; has passed 25 oz. of urine to- day. May 3d.—Urine 24 oz.; Habeat Potass. Bitart. 3j ter in die. Omittantur alia. May 5th.—Urine 18 oz.; swelling of abdomen much increased; thighs and legs greatly distended. Abdomen measures forty inches in circumference. Had Pil. Rhei Co. gr. x. last night. To take Gin |j daily. May llh.—Urine 20 oz.; sp. gr. 1018 • his condition at present seems almost hopeless. The abdomen is enormously distend- ed, with a peculiar diffuse indurated feel over the region of the epigastrium, which however, is tympanitic on percussion. The scrotum, thighs, and legs are greatly en- larged ; appetite impaired; the pulse 86, weak. To be dry cupped over the loins. To have Gin % ij daily. May 9th.—No change. Habeat Potass. Bitart. 3 ss ter in die. May 11th.—Urine 34 oz.; sp. gr. 1015 ; still highly coagulable; numerous casts of tubes are seen in the urine under the microscope. May 15th.—Urine 38 oz.; sp. gr. 1014 ; is less coagulable; complains of severe frontal headache. To continue with the Bitartrate of Potass. May 16th.—Urine 64 oz.; sp. gr. 1010. May 11th.—Urine 58 oz.; sp. gr. 1013; no headache; bed-sore on sacrum; right side more swollen than left (he lies on his side); bowels costive. Habeat Pil. Colocynth. Co. gr. x hord somni. May 18th.—Urine 67 oz. ; cedema of limbs very much diminished; swelling of abdomen less. May 21st.—Urine 68 oz.; sp. gr. 1010 ; appetite good; pulse 96, full and strong. May 22d.—Urine 120 oz. May 23d.—Urine 128 oz.; sp. gr. 1014; it still contains albumen in considerable quantity; the abdomen has greatly dimin- ished in size, and the thighs and legs are of natural appearance, though there is some pitting on pressure at the ankles; every second day of late he has been attacked about noon with a severe frontal headache. R Quince Sulphatis gr. iij ter die sumend. May 24th.—Urine 107 oz.; sp. gr. 1018; still contains much albumen; no headache. May 25th.—Urine 126 oz.; sp. gr. 1016; very slight headache to-day; has taken four of the quinine powders. Still takes the Bitartrate of Potash. May 28th.—Urine 100 oz.; sp. gr. 1020. May 30th.—Urine 50 oz. May 31st.—Urine 80 oz.; sp. gr. 1014; perfectly free from all trace of albumen; cedema of legs and ascites have com- pletely disappeared; no headache; appetite good. June 8th.—No return of the albu- men in urine; quantity varies from 60 to 114 oz. daily. June 9th.—A slight trace of albumen in the urine to-day, and feet slightly oedematous. June 15th.—Still a faint trace of albumen in the urine ; his ankles become oedematous if he sits up long. June 19th.—Urine 100 oz. in twenty-four hours; sp. gr. 1010 ; contains an exceed- ingly faint trace of albumen. June 21th.—The quantity of urine passed in twenty- four hours averages 100 oz.; sp. gr. varies from 1010 to 1015; his ankles after he has been long up pit slightly on pressure. July 2d.—Albumen has quite disappeared; bandaging prevents his ankles from swelling. He sits up the entire day. The appetite is good. Urine passed daily about 40 oz. In fact he is quite well. July 3d. —Dismissed cured. Commentary.—In this case the man described his dropsy as being the third attack of the kind he had experienced, although it was by far much more severe than the preceding ones. I found him in the ward at the same time with Cases CLXXIX. and CLXXX., but unlike them, the treatment seemed to have been of no avail. The abdomen was enor- mously distended from fluid collected in the peritoneum and the scrotum; the thighs and legs were also so greatly swollen from dropsy, that to all appearance the case was hopeless. The urine, when heated, presented almost a solid mass of albumen, as if it had been serum of the blood, and bright's disease. 807 the sediment exhibited, under the microscope, numerous fatty cells and casts of the tubes, proving the disease to be renal. A singular circum- stance is, that from his admission in March, until May 11th, notwith- standing a diaphoretic, purgative, and diuretic treatment had been em- ployed, he continued to get worse, and the anasarca increased. In April, also, he had taken the bitartrate of potash in drachm doses without benefit. But after I resumed the same remedy in May, in half drachm doses, its diuretic effect was extraordinary. From the 11th to the 28th of May, the quantity of urine was greatly increased, and I ordered it to be measured daily. On some occasions 126 oz. of fluid were voided, and coincident with this diuretic effect, the enormously swollen abdomen, scrotum, and inferior extremities diminished in size, and gradually returned to their normal condition. On the 31st of May there was no albumen in the urine. The ankles still remained puffy, especially after sitting up for any time, but on the 3d of July he was dismissed perfectly well. The anasarca in this case had reached its ultimate limits, the scrotum was as large as an adult head, the prostration of the patient was extreme, and we daily feared the coming on of coma and sloughing sores on the back. Although dry cupping was tried over the loins on the 7th of May, I have myself no doubt that the good effects are entirely to be at- tributed to the diuretic ordered on the 9th, and the increased discharge of fluid from the kidneys which followed. The cases now recorded, in which advanced Bright's disease was per- fectly cured, exhibit the groundlessness of the fears entertained by some as to the use of diuretics in that disease. In all they were freely em- ployed, and it may be observed that improvement invariably coincided with the coming on of the increased flow of urine. The case of Herdmann (Case CLXXXII.) is extraordinary in this respect. Case CLXXIX. also, in which there was a permanent cure of albuminuria in connection with hepatic disease, may be consulted with advantage, Case CLXXXIIL*—Second Attack of Albuminuria with Anasarca—Dis- missed relieved. History.—Mary Donaghan, aet. 43—admitted July 12th, 1854, out worker. She states that about three weeks ago, she came home from her usual employment in the open fields in good health, but awoke next morning with pain in the epigastric region, and found her legs, arms, body, and face, much swollen. She was not aware of having been exposed to unusual cold or wet previously, and had no shivering. She had no pain in the loins, and passed her urine in usual quantity. Two years ago, she was ad- ■nitted into this hospital, suffering in the same way as at present. The swelling of her body at that time, however, was much greater. Symptoms on Admission.—On admission, her lower extremities only are oedema- tous, pitting on pressure. Her skin is moist, and she perspires moderately. Urine passed in normal quantity. On standing, a thick white deposit subsides, which, under the microscope is seen to consist of epithelial scales, numerous tube-casts filled with oily globules, and compound granular bodies. Urine deposits a considerable coagu- lum by heat and nitric acid, also an abundant precipitate of chlorides by nitrate of silver; sp. gr. 1012. She complains of pain on pressing firmly the left lumbar region. Her ton Bitart. Potass. 3 iss; Pulv. Gambog. gr. iv. M. To be taken immediately, and repeated in six hours if necessary. Jan. 11th.—The bowels were well opened on the 15 th, the stools being of thin consistence after the second powder, which afforded considerable relief; but they have not been opened since; ap- petite still bad, but less thirst. The urine to-day is of nearly natural color; sp. gr. 1022; quite as coagulable as before; the quantity passed in the last twenty-four hours is * Reported by Mr. Wm. Calder, Clinical Clerk. BRIGHT S DISEASE. 809 58 oz., with a slight sediment of urate of ammonia. Ordered a scruple of Bitartrate of Potass three times a-day. Jan. 19th.—The quantity of urine passed yesterday was 60 oz., but to-day it has diminished to 36; he complained of much thirst, and was ordered cream of tartar water as a drink; he did not sleep well during the night, and is somewhat incoherent in his remarks to-day, though quite sensible when promptly spoken to; bowels still costive; repeat the powder of Bitartrate of Potass and Gam- boge ; to have ten grains of Dover's powder after the bowels have been well opened. Jan. 20th.—Was a good deal better last night, felt himself warm and comfortable after the Dover's powder, but he did not sweat; he has had three loose stools since; the quantity of urine is now 50 oz.; sp. gr. 1020 ; still highly coagulable; his thirst is considerably (fiminished. Jan. 22d.—The urine examined under the microscope yesterday exhibited a few pale casts of the urinary tubes, which are also present to- day ; during the last two days he has passed about 58 oz. of urine in the twenty-four hours, and he states that altogether he feels much better. March 5th.—Since last report has gradually improved in health. To-day wishes to go out, as he now has no complaint but weakness; voids from 50 to 60 oz. of urine daily. It is of rather pale color; sp. gr. 1020 ; about one-sixth coagulable. A few sibilant rales are heard occa- sionally over the chest, but otherwise the systems are healthy. Is dismissed accordingly much relieved. Commentary.—In this case the diaphoretic plan of treatment was tried at first, but with inconsiderable success; It is true the oedema disappeared from the legs, a result probably as much owing to the recumbent position and general comforts of the hospital as to the medi- cines employed. When the bitartrate of potash was administered, after- wards combined with purgatives, the effects were more rapid, and the anasarca soon disappeared. The coagulability of the urine, however, still continued, though in a diminished degree, when he left the house. Case CLXXXV.*—Third Attack of Albuminuria with Anasarca— Dismissed relieved. History.—James Smith, aet. 38—admitted 25th November, 1852. States that he enjoyed good health till about three and a half years ago, when after exposure to a draught of cold air, his ankles began to swell, which swelling in four days extended up to the thighs, and induced him to apply for admission to the hospital, where he remained three weeks and was dismissed cured. The same symptoms reappeared in twelve months, and he was again admitted a patient, remained for a few weeks, and went out, feelin°- quite well. He continued in excellent health till four months ago, when he began°to complain of shortness of breath and palpitation when at work; the palpitation wa*s reduced by cupping, but the dyspnoea continued upon taking exertion. Four weeks a^o the swelling at the ankles returned, and he was again admitted into the hospital,°ward 6, where3 he has been under treatment till the date of his admission into the'clinical 'ward. His habits were rather intemperate previous to his first attack, but since then he has never indulged in any kind of intoxicating liquors. Symptoms on Admission.—On admission, there is some cedema of the limbs and trunk, which pit slightly on pressure; the skin generally is very dry, but of the usual temperature. The quantity of urine voided in the twenty-four hours is 66 oz.; it is of a pale straw color, slightly turbid, and highly coagulable; sp. gr. 1014, depositing a slight sediment like thin whey. Viewed under the microscope, it presents numerous fragments of desquamative casts; some very long, some containing nuclei and granular celfs more or less fatty, and some filled with minute fatty molecules. There are nume- rous pus cells; some epithelium cells, isolated and in groups, from the ureter or bladder There are numerous columnar crystals of uric acid, and some mineral salts a^re-ated ™ masses of minute anSular crystals- T,onSurne, clea? •?* ™oist! ,aPPetite good -"bowels regular ; pulse 68, of moderate strength. There is slight irregularity of the heart's action; first sound prolonged, and accompanied with a soft blowing mur- mur heard loudest at the apex. Other functions normal. > Progress of the CASE.-He was dismissed at his own desire on the 29th of Ao- vember, but returned with all his former symptoms aggravated on the 21th of December. * Reported by Mr. Alexander T. Macarthur, Clinical Clerk. 810 DISEASES OF THE GENITO-URINARY SYSTEM. He states that after leaving the hospital he returned to his usual employment for about a week, when he caught cold, and he has been confined to the house ever since. The cough became very severe, with dyspnoea and great debility after passing his urine. On examination, the quantity of urine excreted is 50 oz.; it is passed without pain; is of pale color resembling whey, is slightly turbid, and deposits, on standing, a small quantity of white sediment, which, on examination by the microscope, presents nume- rous casts, as before noticed, but no crystals; sp. gr. 1013, highly coagulable. On auscultation, sibilant rales are heard all over the chest, expiration prolonged, but no dulness on percussion. He has a frequent cough, with frothy mucous expectoration. R Sol. Antim. 3 ii; Mist. Camph. § iv ; Misce. Sumat § ss quartd qudque hord. Descendat in balneum calidumsecundd qudque node. Dec. 29th.—Still rather feverish, complains of intense thirst, constant craving for drink, which is unrelieved by water. To have as drink § xij of milk mixed with 3* vj of lime water. January 1st.—Cough much the same as on admission; cedema of legs much diminished, but the skin is still dry, diaphoresis never having been induced. About 90 oz. of urine are passed in the twenty- four hours, still very coagulable with heat and nitric acid ; slight deposit, still contain- ing granular casts of the urinary tubes. Jan. 6th.—Cough much relieved; pulse 68, of good strength; swelling of the legs now quite gone; urine passed in large quantity; still complains of great thirst. Continuenter medicamenta. Jan. 13th.—Voided 130 oz. of urine during the last twenty-four hours; has still considerable thirst; pulse 80, of good strength. Expresses himself as feeling quite well. On standing for twenty- four hours, the urine deposits a slight sediment, in which casts of the urinary tubes are still visible, crowded with fatty granules. Jan. 11th.—Feels better than he has done for several years, and wishes to return home. He is accordingly ordered to be dismissed. Commentary.—In this case it was evident that improvement had commenced on his entering the clinical ward, the urine was passing copiously, and diuretics were not directly indicated. Under these circum- stances the diaphoretic plan of treatment was persevered in, and although not with the result of entirely freeing his urine of all trace of albumen, yet with such good effect, that he insisted on leaving the house, which he did nearly well. In the last three cases it will be observed that great relief was experienced, although perfect recovery was not established. The dropsi- cal symptoms were removed, whilst the albuminuria remained, a condi- tion which constitutes the majority of those cases which enter into the hospital, and are dismissed as " relieved." Case CLXXXVL*—Albuminuria, with general Anasarca, terminating fatally— Waxy Kidneys, Spleen, and Liver, with Extensive Deposition of Tubercle. History.—Sarah Wilson, set. 7—admitted November 11th, 1853. Three years ago she suffered from scarlatina, and has ever since been a weakly child, with a capricious appetite. In the course of last summer, oedema of the feet and legs was first observed, together with diarrhoea, which has continued more or less ever since. Symptoms on Admission.—On admission, her countenance is puffy and pallid, and the whole surface blanched. Her feet and legs are oedematous, pitting on pressure. The urine is of a pale color; sp. gr. 1006. On applying heat, and adding nitric acid, a coagulum is thrown down, which occupies a space in the test-tube equal to that of half the quantity of urine. She has never felt any pain in the lumbar region. Tongue moist, and covered by a slight fur; no thirst; appetite good. The abdomen is greatly distended, and there is distinct fluctuation. Pulse 86, weak and compressible; cardiac sounds normal. She has no headache and sleeps well at night. B> Acet. Potass. 3 i; A^th. Nit. 3 ij ; Syrupi 3 i; Aquce §" v. M. A table-spoonful to be taken three times a-day. Progress op the Case.—November 11th.—Diarrhoea continues and she lies in a very weak state. R Mist. Cretm § iv. An ounce to be taken three or four times a-day. To have 1 oz. of gin daily. Nov. 25th.—Urine passed in great quantity; sp. gr. 1002; * Reported by Mr. Peter W. Wallace, Clinical Clerk. BRIGHT'S DISEASE. 811 not so coagulable. The diarrhoea, which abated for a few days after last report, has again returned. Ordered an astringent mixture. Nov. 30th.—The pufliness of the face, which, on some days after her admission, abated considerably, is now as bad as ever. Her urine has been passed involuntarily for the last three days; the diarrhoea is less severe. Dec. 10th.—Since last report, the cedema has wholly disappeared. The fasces and urine are both passed involuntarily. The constant dribbling of the latter over the labia and nates has produced excoriation. She takes her food pretty well, but vomits it occasionally. Her pulse is very feeble, and her strength much im- paired. She is at present taking 2 oz. of gin, and an equal quantity of wine daily. For the last five or six days she has been very drowsy, sleeping almost constantly, although she can easily be aroused, and answers questions readily. Dec. 13th.—The cedema has not returned, but the drowsiness gradually increased until this morning, when she expired. Sectio Cadaveris.—Forty hours after death. Body greatly emaciated ; slight oedema of feet. Thorax.—The lungs, which looked quite healthy, presented to the touch some indurated points; these, on being cut into, were found to consist of clusters of minute grey granulations, generally about the size of small marbles. At the apex of the right lung was a small cretaceous concretion. The heart weighed 3 oz., and was quite healthy. Abdomen.—There were adhesions between the upper surface of the liver and the diaphragm. The liver weighed 4 lb. There was a little hepatic congestion, but the intervening tissue was pale; the whole presented the usual appearance of the waxy degeneration. The spleen weighed 2\ ounces, specific gravity 1054. It felt firm, and presented on section a waxy appearance. Throughout its substance were numerous enlarged semi-translucent, grey malpighian bodies, closely aggregated together. Their average diameter was about the 16th of an inch. The kidneys were enlarged, weighing each 6| oz. On stripping off the capsule they presented a mottled appearance from the presence of irregular vascularity, contrasting with the pale cortical substance. On section they presented a well-marked waxy appearance; the cortical portion was of a pale yellowish color; the striae generally absent or indistinct. At some places there was a number of minute opaque yellowish spots. On opening the intestines, tubercular ulcers were found; they occurred in the lower third of the small intestine, presented the usual characters, and occupied the whole circumference of the gut. The mesenteric glands were much enlarged, and were infiltrated with tubercle. Microscopic Examination.—The liver was found to contain much fatty matter, both free and contained in the hepatic cells. But the majority of the cells were pale and very indistinct (see Fig. 295, p. 230). Thin sections of the cortical substance of the kidneys presented a very transparent appearance, particularly the malpighian bodies. At some places, there were collections of fatty granules, but this did not occur very frequently, and only in isolated points. The enlarged malpighian bodies in the spleen contained a translucent matter, closely resembling colloid, and which presented the blue reaction of cellulose on the application of iodine and sulphuric acid. Commentary.—This case presented all the symptoms of Bright's disease, in a young girl who had been in a state of ill health for three years, in consequence of an attack of scarlatina. On dissection after death, the kidneys, liver, and spleen were found to have undergone that chronic condition now known as waxy, and which is very commonly associated, as in this case, with tubercle. The nature of the morbid alteration has been previously referred to (see p. 249). Case CLXXXVIL*—Albuminuria—Excessive amount of Urine—Phthisis Pulmonalis— Waxy Liver, Kidneys, and Spleen. History.__Thomas Keegan, set. 40—admitted December 13th, 1848. Patient states that he was in the enjoyment of good health till last May, when he first experienced intense thirst, and began to drink large quantities of water. ^ At the same time he observed that his urine became very much increased in quantity, and he required to get up three or four times in the course of the night to micturate. He had no pain in the region of the kidneys or on making water. This polydipsia and excessive mictu- * Reported by Mr. George Shearer, Clinical Clerk. 812 DISEASES OF THE GENITO-URINARY SYSTEM. rition continued undiminished till five months ago, when he experienced a dull aching pain in the small of the back. This pain }n the loins afterwards degenerated into a feeling of weakness, which has continued ever since. On the 29th October he went into the Glasgow Infirmary, complaining of loss of appetite, great thirst, weakness, and loss of flesh. He remained in this Institution for six weeks, and took several remedies without any benefit. During the last fortnight his appetite has returned, and he has been much better. Symptoms on Admission.—There was dulness on percussion, and cracked-pot sound over the upper third of left lung in front. Over this part there was heard tubular breathing and loud mucous rales; over the right apex prolonged expiration. Posteri- orly percussion equal on both sides. Crepitation and sibilant rales on left side. There is frequent cough, with copious muco-purulent expectoration. Tongue dry, clean, red, and tremulous. Appetite good but thirst excessive. Drinks, as nearly as can be ascer- tained, a gallon of water daily. Bowels regular. He is much emaciated; skin dry. He has not perspired any for several weeks. No cedema or ascites. The urine acid, unu- sually transparent, sp. gr. 1010, shows a considerable quantity of albumen, chlorides abundant, no sugar. Large waxy tube casts were detected in the urine, under the mi- croscope. There is slight tenderness on pressing firmly over the region of the kidneys. Progress of the Case.—December 15th.—He passes from 100 to 130 oz. of urine daily. Has expectorated a considerable quantity of muco-purulent matter. His mouth and fauces were so dry this morning that blood flowed on dragging the tongue from the palate, to which it adhered by clammy glutinous secretion. There was a slight discharge of blood after blowing bis nose also. December 18th.—Passed 176 oz. of urine on the 16th, 128 oz. on the 17th, to-day 82 oz., and drinks large quantities of water. Ordered to be dry-eupped over the kidneys. To drink soda-water, and milk and water instead of simple water. December 20th.—Urine 112 oz. Ordered a table-spoonful of Oleum Morrhuce three times a-day, and the following mixture :—R Spt. ABtheris Nitrici 3 i; Sol. Mur. Morph. 3 ss; Mist. Camphorce § ij. M. Half the mixture at bed-time and the other half in three hours if the cough is troublesome. December 21st.— Had a good sleep after the mixture, but felt drowsy and sick all day. Pupils contracted at morning visit. Passed 112 oz. of urine. 22d.—Feels very well to-day. Passed a good night. Urine 64 oz. December 25th.—Has still a feeling of weakness and heaviness in the loins, and breathes heavily and with some difficulty. Expectoration purulent and considerable in quantity. Slight cedema of left foot observed this morning. Urine diminished to 54 oz. in the twenty-four hours. December 26th.—Passed 48 oz. of urine since yesterday. Has had no stool during last twenty-four hours. Complains of great sickness to-day, and vomited his- dinner. Ordered Naphtha Medicin. % ss; Tr. Card. Co. § i; M. A tea-spoonful occasionally in a glass of water, ty Pulv. Jalapce Co. 3 ss; mitte tales xij ; one three times a day. Ordered also 4 oz. of gin daily. December 21th.—Passed a very uncomfortable night, with frequent moaning and sterto- rous breathing. At 1 p. m. his respiration became very slow and labored, a mucous rattle was heard in his throat, and at forty-five minutes past one he expired. Sectio Cadaveris.—Forty-eight hours after death. Body a good deal emaciated. Thorax.—Very dense adhesions at the apices of both lungs. The upper lobe of each lung felt firm and dense. In the upper lobe of the left lung there was a cavity of tolerably regular oval form, and nearly the size of a hen's egg. The lower extremity communicated with a smaller one of an irregular form. These cavities were lined by a well-organized lining membrane, having a cheesy-looking matter adherent to it at many places, and here and there the cavities were crossed by bands of condensed fibrous tissue. The pulmonary tissue around them was greatly condensed. There was much yellow tubercle scattered through the remainder of the lung, and several vomica;. One or two small cavities and a good deal of tubercle were found scattered through the upper lobe of the right lung. About two inches below the apex, and nearly in the centre of the organ, was a cretaceous concretion, about the size of a pea, enclosed in a capsule of dense fibrous tissue. About an inch below this there was a second concre- tion. The middle and lower lobes contained little tubercle. Bronchial glands enlarged, indurated, and loaded with black pigment. Heart healthy. Abdomen.—The liver was much enlarged, and was of unusual firmness and density. On section it presented the waxy degeneration, well marked, the surface of section being dry, of a somewhat mottled yellowish-red color, with a peculiar translucent appearance; lobular structure very indistinct. The organ weighed 6 lbs. 6 oz. The bright's disease. 813 spleen was enlarged, 8\ oz., and felt somewhat dense. On section it was found to be pretty abundantly studded with clear Malpighian bodies, resembling grains of boiled sago. The kidneys were enlarged, weighing 15£ oz. On stripping off the capsule, the surface of the gland was found quite smooth, very pale, of a whitish-yellow color, and of unusual density. The surface was somewhat mottled, owing to some patches of vascularity, contrasting strongly with the generally anaemic condition. On section the cortical substance was found hypertrophied, and had a pale, translucent appear- ance. The medullary portion was moderately congested. Almost all the branches of the renal artery in each kidney contained whitish clots; some of them were firm, others partially softened. Some chronic tubercular ulcers were found in the lower part of the small intestine, and* in the upper part of the large intestine. Microscopic Examination.—On examining microscopically a little of the softened portions of the clots in the renal arteries, it was seen to consist chiefly of granular matter with a comparatively small number of cells, having the character of pus globules. When a section of the kidney was examined, the minute arteries were found to be much thickened. The cells and other structures of the kidney presented the usual characters of waxy degeneration. Commentary.—After death both kidneys, the liver, and spleen exhibited a chronic state of waxy degeneration. Death was occasioned by exhaustion from the pulmonary disease, vomiting, and impeded nutrition. This case was published in the last edition under the head of Polydipsia, and was the first in which the passage of a large amount of urine during the progress of Bright's disease attracted my attention. In the previous case, however, it will be observed that the urine also was passed in great quantity. Many other such cases have since entered the clinical wards, three of which follow. Case CLXXXVIIL*—Albuminuria with great increase of Urine- Waxy Kidneys, Spleen, and Liver. History.__Mary Muirhead, set. 17—admitted March 3, 1860. She states, that at the age of five she lost the power of her lower limbs, and that shortly afterwards an abscess formed on her back, between the shoulders, and ultimately burst, when she recovered the use of her limbs. Her spinal column is beut outwards, at an acute angle, opposite the second dorsal vertebra. She states that, excepting this abscess and the discharge from it, which continued nearly to the date of her admission, she has enjoyed aeneral immunity from disease. Four years ago she had scarlatina, but has since been m her usual health. Her respiration was always difficult on exertion, and this has increased during the last three months, since which time she has had cough, at first short and dry,°but more recently accompanied by sputum. The patient states that since January she has been subject to lumbar pains, at times so severe as to prevent her working. A month after this, or three weeks previous to admission, she observed that she was'passing a much larger amount of urine than was natural, and at the same time her ankles became oedematous, and her face at times puffy. Her weakness in- creasing, she applied for and obtained admission to the Infirmary. Symptoms on Admission.—On admission heart sound healthy; pulse 100, small and feeble There was considerable harshness of respiratory murmurs all over the chest Tongue clean, but rather dry; thirst great; appetite good; bowels regular; slight ascites • the liver and spleen not enlarged; legs slightly oedematous; skin pale and dry Urine was copious, about 50 to 70 oz. per diem ; sp. gr. 1005; containing much albumen and few chlorides. A sediment was deposited on standing, which con- tained numerous hyaline tubecasts, involving here and there a cell which had under- gone fatty degeneration. Habeat Tr. Ferri Mur mxv ter die. Steak diet. Milk. Progress of the Case —Patient remained under observation without much change for two months, during which time her urine ranged from 50 to 150 oz. daily. On only two occasions during these two months did it fall below 50 oz The ascites grad- ually increased. About the beginning of May she was seized with diarrhoea, which continued notwithstanding the employment of various astringents. The cough and dyspncea increased, with advanced dropsy of the legs and abdomen. The daily amount * Reported by Mr Wm. Ward Leadham, Clinical Clerk. 814 diseases of the genito-urinarv system. of urine fell to 30 or 40 oz., continued albuminous, and contained casts with more fatty renal cells than formerly. She died exhausted May 20th. Sectio Cadaveris.—Thirty hours after death. The lungs were found free from tubercle, but the bronchi congested and full of mucus. Heart small, weighing less than four oz.; spleen large and waxy; liver large and waxy, weighing 1 lb. 15 oz.; kidneys large, weighing together 13* oz. The cor- tical substance was very pale, and presented all the characters of the waxy degenera- tion. There was no ulceration of the intestines. Commentary.—In this case it will be observed, that as a result of chronic spinal disease, followed -by scarlatina, Bright's disease appeared accompanied by frequent desire to pass water, and that from 70 to 80 oz. of urine, which she voided daily on coming into the house, it subse- quently increased to 150 oz. I was much struck with this circumstance, and at once recognised its similitude to that of Keegan, previously reported, who died from waxy degeneration of the kidneys and other organs. Although the notes of the examination after death are meagre, the existence of the lesion cannot be doubted. Case CLXXXIX.*—Albuminuria—Syphilitic Ulcerations of Throat— Enlarged Spleen and Liver—Leucocythemia— Waxy Degeneration of Kidneys, Liver, and Spleen. History.—Edward Burns, a laborer, set. 30, married—admitted January 12, 1860. Patient states that he has had very little sickness, and, in particular, never had syphilis; but he confesses to have suffered from buboes, resulting from a strain. The prepuce is remarkably contracted, and his throat presents syphilitic-looking ulcerations. Symptoms on Admission.—His throat was ulcerated, his voice was husky, and he had a harsh cough, with occasional muco-purulent expectoration. At the apex of the right lung there was harshness of respiration, but no increase of vocal resonance; cardiac sounds normal; pulse 80, small and feeble. Blood poor in corpuscles; the white rela- tively more numerous; the red pale and flabby, with a tendency to tail, and form into rows like a string of beads rather than a rouleau of coins. Tongue clean; appetite pretty good; bowels open. Hepatic dulness extends from the sixth rib to the umbilicus. The spleen is also considerably enlarged. The urine is highly albuminous, of low spe- cific gravity, and contains a few waxy tube casts. Patient stated that he never observed anything particular about his urine; but on its being, by Dr. Bennett's direction, measured, it was found to amount to upwards of 160 oz7 daily. It was always of low sp. gr., and contained no trace of sugar. There was no cedema of the legs, unless oc- casionally, when he had been working hard, and then his ankles became swollen at night. During the four months he remained in the house his general health improved, and his liver diminished slightly in size. The amount of urine varied from 140 to 230 oz. daily, and he drank from 60 to 120 oz. of fluids. Latterly the quantity discharged was from 90 to 120 oz. daily, and his blood presented a more healthy appearance. The treatment consisted of astringents and Argent. Nit., to the ulcerating of the fauces, which healed, and of Tr. Ferri Mur. and Iodid. Potassii internally, and occasional dry cupping over the loins. He was dismissed, at his own request, April 30th. Presented himself 1th April 1861.—His general appearance is better than it was last year. He states that he is quite well, but that the daily amount of urine has not further diminished. It is highly albuminous, of low specific gravity, and contains casts. His tongue is clean ; his appetite good; his bowels are moved twice a-day. The liver is much enlarged, measures eight inches vertically, and extends considerably across the epigastrium to the left side. The spleen is also enlarged. The blood con- tains an excess of white corpuscles. Expiration is harsh and prolonged at the apices of both lungs. The heart-sounds are altered in tone, but not of a blowing character. 13th August 1862.—The patient again presented himself. He is more emaciated. States that from increasing debility he has been unable to work for a month past. He still makes large quantities of urine, which is albuminous, but not so intensely as before. It deposits a sediment containing hyaline tube casts, with oil-granules here Reported by Mr. Colville Brown, Clinical Clerk. bright's disease. 815 and there arranged in groups, as if resulting from disintegration of cells. There has been no dropsy of late. The liver, though still enlarged, is decidedly diminished since last report. He complains much of his breathing. 22d September 1863.—He complains much of difficulty of breathing, and of cough and headache when he attempts to stoop; he has also dropsy; and from all these symptoms feels himself unable to follow his usual work. The amount of urine is still large. He is obliged to rise three or four times every night in order to micturate. The urine is albuminous, and contains waxy casts. lie-cdmitted November 6th, 1863, complaining of a further aggravation of his symptoms, and died on the 9th, under the care of Dr. Sanders. Sectio Cadaveris.—Twenty-eight hours after death. The body was somewhat emaciated. Chest.—The heart was enlarged. The aorta was very atheromatous. The lungs were oedematous, and the bronchi congested and full of mucus. Abdomen.—The liver was about the natural size. On its surface were a number of nodules and cicatrices. At the bottom of some of the latter nodules of a pale color were visible. On section, numerous nodules were found scattered throughout the organ; they were pale, dense, and had an appearance exactly resembling bees-wax; their structure was much denser than that of the surrounding tissue. In some nodules there were streaks of fibrous tissue throughout the substance and round the margin, and the greater the proportion of that tissue the deeper were the cicatrices. In the nodules elevated above the surface there were no such streaks, or very few. In those situated at the bottom of deep cicatrices, the fibrous element was abundant, or even in excess of the glandular. On applying iodine to these masses, the whole of the waxy-looking material assumed a brownish-red color, but the fibrous streaks simply assumed a yellow tinge. Microscopic Examination.—Microscopically, the masses were found to present exactly the characters of waxy hepatic cells. They were composed entirely of these cells, enlarged, transparent, and finely granular. In some parts the cell elements were broken down, and a finely granular material containing some oil-globules was present. The fibrous tissue in the masses presented the characters of dense white areolar tissue; and where it was most abundant the cells were most atrophied. Throughout the rest of the organ the cells were little affected with the waxy degeneration, but some of the small vessels showed it distinctly. The kidneys were somewhat contracted in the cortical substance, and presented a very well-marked instance of the waxy degeneration of the vessels and Malpighian bodies. There was some degree of waxy degeneration of the villi of the small intestine; the bowels were otherwise natural. Commentary.—In this case, similar phenomena were observed as in the former cases, the amount of urine passed daily having increased to the extent of 230 oz. daily. A careful examination after death revealed the waxy degeneration. Case CXC*—Enlarged Liver and Spleen—Leucocythemia, and Fibrinosis of the blood—Albuminuria— Waxy Kidneys. History.—Archibald March, set. 29, a shoemaker, married—admitted February 15, 1860. Iu April 1859, patient was in the Infirmary on account of enlargement of the liver and spleen, with slight leucocythemia. He was dismissed considerably relieved; but having felt, of late, great oppression on taking food, with occasional bloody vomitings and increasing general debility, he was readmitted. States that, some years since, he had syphilis, which was followed by eruptions, nodes, etc., and ultimately by the symptoms of which he now complains. Symptoms on Admission.—His general appearance is cachectic and sallow; hia chest covered with brownish patches of pityriasis nigra, which have existed for some years. There is no oedema. Pulse is full, 82 per minute. Cardiac dulness 2| inches transversely. There is a soft blowing murmur, with the first sound, loudest at the base. There is a slight relative increase of the colorless corpuscles of the blood, and the red corpuscles have a tendency to tail. (See Fig. 60, taken from this case.) Tongue is moist; appetite not good; thhst great. He vomits occasionally after eating. Bowels constipated. The liver measures nine inches in a line vertical to the * Reported by Messrs. Thos. Annandale and P. M. Braidwood Clinical Clerks. 816 diseases of the genito-ueinaky system. nipple; and there is great tenderness on pressure over the whole area of dulness. The splenic dulness, laterally, is 6-J- inches from above downwards. Urine was of a pale amber color; specific gravity 1009; no albumen. March 3d.—Jt was ascertained that jiis urine amounted to 110 ounces daily, and it continued at a similarly high standard, sometimes falling as low as 90 and rising as high as 130 ounces. March 10th.—A trace of albumen was observable. It steadily increased in amount; and, soon after its appearance, a very few waxy or hyaline casts were to be detected by the microscope. Notwithstanding the increased flow of albumen, the patient, under a tonic treatment, with liberal diet, so far improved as to be able to leave the hospital, to resume work, on March 26th. He has been seen at intervals since. December 3d.—His complexion sallow and cachectic as before; abdomen free from tenderness; liver measures, in line of right nipple, 1\ inches, and the spleen barely 5 inches at the side. He does not know exactly how much water he makes daily; but thinks it is less than when he was in the Infirmary. It is distinctly albuminous. No dropsy. The glands of the neck on both sides have become enlarged within the last ten days. The blood is in the same condition as formerly. 4th February 1861.—The liver and spleen have further dimin- ished in size. His appearance is somewhat less cachectic. For some days he has had a pain in the neighborhood of the umbilicus, and along the margin of the liver, aggra- vated on movement or on pressure, and after eating. The stools are of a dark color, and contain some bright red blood. He has no piles. The amount of urine continues high, about 120 oz. daily, and is albuminous. 8th October 1861.—The patient again presented himself; his cachectic appearance is increased; he complains of a severe pain in the lumbar region, and along the spermatic cords. His renal symptoms con- tinue unchanged, and the liver is still distinctly enlarged. Since that time he has re- peatedly been an inmate of the Royal Infirmary; has occasionally worked at his occu- pation of shoemaking, and has of late acted pretty constantly as cook to the Mid- Lothian Militia stationed at Dalkeith. March 21st, 1864.—He continues to make large quantities of water daily, usually upwards of 120 oz. It is still albuminous, but no tube casts have been discovered for some time. The hepatic dulness is diminished to about six inches; the organ is still painful on pressure. He has no nausea, and his Dowels are regular; but on several occasions lately he has had intense diarrhoea, some- times with bloody stools, and has vomited blood-colored matters. November 2d, 1864.— Presented himself at the Royal Infirmary, saying, that he was greatly improved in health, and has been able to work continuously for some months past. The liver and spleen are still further diminished in size, the excess of colorless cells in the blood has disappeared, while the colorless corpuscles are healthy. In other respects the same. Commentary.—This man, who is still living, and who has been under my observation for upwards of five years, presented all the phenomena described in previous cases of waxy degeneration of the kidneys, liver, and spleen. The condition of his blood was very pecu- liar, not only presenting all the characters of leucocythemia, but an amount of fibrin so great as to be deposited in fibres the moment it was placed on a glass side, and examined with the microscope—the colored corpuscles of the blood also were altered in form, presenting an oval shape, tails, etc., as previously figured. (See Fig. 60.) At one period, also, he probably had waxy degeneration of the intestinal mucous membrane. In 1860 we saw the albuminuria appear—the amount of urine passed daily increased to 130 oz. daily—and, from all the circum- stances of the ease, there could be no doubt, that a most extensive waxy degeneration, with enlargement of the kidneys, liver, and spleen, existed. Notwithstanding the profound cachexia, weakness, and prolonged symp- toms which were unusually severe, he has latterly become much better. The liver and spleen have diminished one-third of their previous bulk, and he has so much improved in health as not only to declare himself well, but to continue his daily occupation without fatigue. The future progress of this interesting case will be watched with unceasing interest. The three previous cases strongly attracted my attention, and that bright's disease. 811 of the class, during the spring of 1860, in consequence of their simi- larity to that of Keegan, in which I first noticed the great increase of albuminous urine, in connection with waxy degeneration of the kidneys and other organs. Dr. Grainger Stewart, who was my resident physician at the time, has since then taken great pains to collect a con- siderable number of these cases, which he has published.* From many well-marked examples of waxy degeneration of the kidneys I have since examined, there can be no doubt that an increase of albuminous urine is a diagnostic symptom of great importance. A study of the five cases I have detailed will be seen to agree with the following description of the symptoms of this lesion by Dr. Stewart:— "An individual who has long suffered from wasting disease, such as scrofula, caries, necrosis, or syphilis, or who, though without palpable disease, is of a feeble constitution, feels an increasing weakness, and begins to pass large quantities of urine, and to drink largely. He is, contrary to his usual custom, obliged to rise repeatedly during the night to make water, and on each occasion passes a considerable quantity. The amount of urine varies from 50 to upwards of 200 oz. daily, always bearing a relation to the amount of fluid drunk, generally nearly equalling it in amount, ov sometimes even exceeding it. The feet and ankles become oedematous after a hard day's work, but return to their natural condition during the night's repose. In many cases there is observed a hardness and swelling in the hepatic and splenic regions, de- pendent on an increase of bulk of the liver or spleen. The patient feels a constant lassitude and unfitness for exertion. His urine gradually becomes albuminous, and a few waxy or hyaline tube casts are to be found in the very scanty sediment which it throws down. It is of low specific gravity—1005 to 1015. The blood presents some peculiarities microscopically; the white corpuscles being somewhat increased in num- ber, and the red presenting a flabby appearance, with a marked tendency to tail,— that is to say, instead of forming into rouleaux, like healthy corpuscles, they become stretched out into long, spindle-shaped bodies. The blood changes I have observed only when the degeneration affected the lymphatic or blood glands. The patient may continue in this state for months, or even years—may, indeed, undergo a temporary improvement—the liver and- spleen becoming diminished in bulk, and the blood resum- ing a more healthy character; but, sooner or later, for the most part, ascites or general dropsy gradually supervene, accompanied frequently by diarrhoea, which is at times found quite uncontrollable. The urine, now very albuminous, diminishes in quantity, so as at times to be almost or altogether suppressed; effusions into the serous cavities or severe bronchitis ensue3; the patient becomes exhausted and sinks, or drowsiness comes on, and the disease terminates amid coma and convulsions." I would refer you to the excellent remarks of Dr. Stewart as to the individual symptoms and pathology of this disease, only begging you to avoid the word amyloid as indicative of the lesion, for reasons detailed at length, p. 250. Case CXCI.f—Albuminuria, with Phthisis Pulmonalis, terminating fatally—Extensive Deposition of Tubercle and Colliquative Diarrhoea— Atrophied Fatty Kidney— Ulcerated Intestines. History.—John Montgomery, set. 60, weaver—admitted November 19th, 1852. States that for several years past he has been exposed to great privations, and that he has been frequently troubled with bowel complaint during that time. The attacks have sometimes been severe, and of long duration, but have generally lasted for a few days only. About a month before admission, the diarrhoea became much aggravated, there having been sometimes as many as twelve stools in twenty-four hours. This has continued more or less since that time, reducing him greatly in flesh and strength. As far as he has observed, he has never passed blood by stool. He has also had a short * Edinburgh Medical Journal, 1861, p. 740; and 1864, p. 97. + Reported by Mr. W. M. Calder, Clinical Clerk. 52 818 DISEASES OF THE GENITO-TJRINARY SYSTEM. dry cough, but only for a few weeks past, and unaccompanied with expectoration or dyspncea. He was brought into the hospital in a state of great weakness and ex- haustion, having fallen down in the street, supposed to be in a state of intoxication. He states that he has not taken any spirits for some days past, although he has been much addicted to intemperance during the greater part of his life. Symptoms on Admission.—On admission, the tongue is very dry, but not furred ■ but there are some sordes on the teeth and gums. He experiences difficulty in deglu- tition, as if there was some obstruction about upper part of sternum; appetite bad • troublesome thirst; no sickness or vomiting; no pain in epigastrium, but frequent griping pains in abdomen. Bowels are very loose: much straining and great tenesmus when at stool; evacuations of an almost watery consistence and reddish-brown color. They present no appearance of blood, but contain a few shreds of mucus. Occasion- ally he passes nothing but a small quantity of frothy slime; no hsemorrhoids. On physical examination of the abdomen, the parietes are tense and retracted. The liver is slightly enlarged, the dulness measuring five inches from above downwards. Chest appears contracted, and does not expand freely. There is no comparative dulness on percussion. The respiration is feeble and the expiration prolonged; under the right clavicle it is of a somewhat tubular character. Vocal resonance is also increased over the same part. At the lower part of right side anteriorly, there is a fine fric- tion sound. Sputum in very small quantity; muco-purulent, untinged with blood. Pulse 124, small and feeble; heart sounds normal; urine sp. gr. 1012, becomes slightly clouded with heat and nitric acid, but no distinct coagulum is formed; other functions normal. R Sol. Mur. Morph. 3 ij; Tinct. Catechu 3 vj; Mist. Cretce §" vj. M. Su- mat § j iertid qudque hord. Ordered to have 6 oz. of wine and steak diet. Progress of the Case.—November 20th.—Wandered a good deal during the night; is exceedingly weak to-day, but the diarrhoea is less severe. Nov. 22d.—Complains more of cough and pain in right side, striking across the chest to the left; no dulness on percussion; still friction on right side with fine moist rales; marked increase of vocal resonance; urine diminished in quantity; of natural color, with slight floccu- lent precipitate on the application of heat and nitric acid. Diarrhoea stopped; pulse 112, small and weak. Nov. 24th.—Was much weaker yesterday, and evidently sinking; too weak for examination of the chest; bowels were once opened; no urine voided since last report. Died this morning at four o'clock, comatose. Sectio Cadaveris.—Fifty-six hours after death. Body somewhat emaciated; very little subcutaneous fat; muscles well nourished. Thorax.—Heart normal; adhesions of both pleurse over limited space of upper lobes. Both lungs contained many scattered groups of tubercle, chiefly miliary; some few of them softened, and with small dry excavations at the apices; the pulmonary tissue around the tubercles mostly indurated and dark colored from carbonaceous in- filtration ; the bronchial glands dark and enlarged. Abdomen.—Stomach and jejunum and upper two-thirds of ileum normal. In lower third several scattered ulcers, not exceeding eight or twelve in number, from one- quarter to three-quarters of an inch in diameter; some of them slightly congested at edges; their characters in all respects those of tubercular ulcers. Colon contracted at lower part. In the ascending portion, there are four or five small tubercular ulcers; the largest half an inch in diameter, edges pale and slate-colored, the floor somewhat indurated. Spleen pale, peritoneal capsule thickened, the organ rather small, no dis- tinct morbid appearance. Liver slightly enlarged, presenting very distinctly, and in a considerable degree, the fatty degeneration. Kidneys unusually small (dimension of right three and a half inches long, one and three-quarter inches broad, three-quarters of an inch thick, left kidney of nearly the same size, weight not ascertained); capsule easily stripped off; surface slightly uneven, not distinctly tuberculated; venous vas- cularity of surface considerable but irregular; on section, cortical substance much diminished (average three-eighths of an inch in diameter from base of pyramids); limiting line of pyramids tolerably distinct; faint appearance of opaque granulations. On examination with a lens, many very minute cysts were discovered in cortical sub- stance ; most of them required a power of half an inch focal distance to bring them into view. A similar power, or even the naked eye, distinguished easily a number of opaque light gamboge yellow points in the cortical substance; the largest was about one-fiftieth of an inch in diameter, accurately limited, and yielding, on being punctured, a fluid of the same color. In the cortical substance there were also some minute haemorrhagic petechise, having the usual appearance of extravasation. bright's disease. 819 Microscopic Examination.—With higlf magnifying powers, the tubuli uriniferi were seen in some places to be of normal character, with the exception of a very few granules in the epithelium; on the contrary, in others, the tubes were crowded with fatty granules. The epithelium generally was normal in form and appearance in the tubes which had fewest granules. In many places the cortical substance of the kid- ney was studded with minute cysts, constituting the third form which they present (see p. 800). In the fluid squeezed from the yellow points, in the cortical substance, there was an immense number of fatty granules, partly loose, partly agglomerated into amorphous collections, partly composing distinct rounded granular masses up to the one-ninetieth of an inch in diameter, and partly contained in cells of a very fine deli- cate transparent character, presenting much of the appearance of a tesselated epithe- lium. The cells of this epithelium were more transparent, and generally one-third smaller than those usually found in renal tubules. Commentary.—In this, as in some former cases, the renal disease was associated with phthisis, but was more chronic, further advanced, and exhibited the ultimate effects of the fatty rather than of the waxy de- generation, The report states that the urine was not highly coagulable, presenting only a slight cloud on the addition of heat and nitric acid. The fluids of the body, however, seemed to have been discharged to a great extent by means of stool. Before death, the urine was suppressed, causing coma. Drs. Christison and Peacock have pointed out how fre- quently Bright's disease is a complication of phthisis, and I have not only confirmed that observation, but observed that this is, in most cases, connected with the waxy degeneration of the renal organs. In the cases previously given, we have seen various examples of the inflammatory, waxy, and fatty forms of Bright's disease. It would be easy to multiply instances where, on dissection, all kinds of intermediate conditions of the kidneys had been observed; but those now recorded, together with such as recovered or were relieved, present the leading characters illustrative of the pathology, diagnosis, and treatment of Bright's disease. A few words on each of these topics may now be added with propriety. Pathology of Briyhfs Disease. Many names have been proposed by various pathologists for the dis- ease called after Dr. Bright. Up to the present time, however, none of them has been sufficiently good to comprehend all those lesions which occasion renal dropsy, with persistent albuminuria. Hence we still retain the designation it has so appropriately borne, to express a disorder characterized by more or less dropsy, caused by obstruction to the renal functions, and accompanied by the presence of albumen in the urine. The nature of the obstruction to the renal function differs under a great variety of circumstances, but such as occasion dropsy, with per- sistent albuminuria, it appears to me may now be classified under three heads—1st, Inflammation, acute or chronic• 2d, Waxy degeneration; 3d, Fatty degeneration. 1. The Inflammatory Form.—This may be acute or chronic; the first is generally induced by all those causes which excite inflammation in other internal organs, and is ushered in by rigors and febrile symptoms, and accompanied by pains in the lumbar region, and the phenomena generally described as those peculiar to nephritis. (See Nephritis.) The chronic disease may follow the acute, may come on more slowly, as the 820 diseases of the genito-tjrinary system. result of the same causes, or proceed so imperceptibly from causes which have escaped observation, that the occurrence of dropsy, more or less extensive, may be the first symptom which excites attention. On testing the urine chemically, it is found to be albuminous, and on examining the sediments microscopically, various kinds of casts, with epithelial cells, blood corpuscles, different salts, and other morbid products, may be seen. These casts of the uriniferous tubes are finally molecular and fibrinous (exudative casts), or mingled with the fibrinous matter, there are epithelial cells and free nuclei of the tubes {desquamative casts). Other products, which vary according to the period of the disorder and the tissues in- volved, may also be present, to which we shall allude under the head of diagnosis. On examining the kidneys of individual^ who have labored under this form of the disease, we find that in the acute stage they are more or less congested and tinged of various colors, from a bright red to a dusky brown. The surface is not unfrequently covered over with minute ecchymotic spots, dependent on the extravasation of blood into the tubes, in their convoluted portions. The excessive congestion and extravasation of blood, by obstructing the tubes and interfering with the secreting function of the organ, form the chief source of danger in these cases. There may also be frequently observed a fibrinous exudation filling the tubes, in which are intermixed the epithelial cells, and here again the extent of the obstruction so occasioned is, sometimes without much con- gestion (Case CLXXL), commensurate with the danger of the case. As the disease becomes more chronic, the intense uniform coloration dimi- nishes, leaving irregular arborizations, which mottle the surface—the blood extravasated is absorbed—the exudation, if not dislodged and passed in fragments by the urine, gradually disintegrates, and may or may not undergo the purulent or fatty transformation. This, by long- continued pressure, causes permanent obstruction of the tubes and atrophy of the renal structure, so that at last the organ becomes smaller and smaller, less and less able to perform its functions, and ultimately causes death (Case CXCI.) 2. The Waxy Form.—This form of the disease is generally chronic, and for the most part accompanies scrofulous, syphilitic, and other cachectic complications. Dropsy, and a peculiarly sallow and emaci- ated look, constitute its chief symptoms; and the urine, as the disease slowly progresses, becomes first increased in quantity, and then more and more suppressed, death taking place by exhaustion or coma. The urinary sediment is usually small, and presents hyaline casts of the tubes {waxy casts), with a few epithelial cells, unusually colorless and transparent. Not unfrequently, however, at an early period, desquamative casts, with little fibrin, and composed of closely aggregated cells, of the tubes, may be seen. This form of the disease, though mixed up with the various other lesions which usually accompany it, may now in the majority ot cases be distinctly determined, the description given by Dr. Stewart serving for the most part to render it recognizable (p. 817). On examining kidneys which have undergone the waxy degeneration, we generally find that they are more dense to the feel than natural, some- times smaller, at others larger than usual, and of a color resembling bright's disease. 821 various shades of dirty bees' wax, or of a light fawn tint. On section the surface is smooth, and the edges more or less translucent; a circumstance dependent on the diminished vascularity which everywhere prevails, and a pecu- liar transparency which all the struc- tures of the organs have undergone. A thin slice, when magnified under a power of 250 diam. linear, exhibits the vessels of the Malpighian bodies more transparent and refractive than usual (Fig. 475). The tubules are colorless, often destitute of epithelium, and of a peculiar whiteness. Such cells as are discovered have their nuclei more or less atrophied, and closely resemble Fi^. 475. those seen in the liver when similarly affected (see Fig. 319, p. 249). Indeed, this change in the kidney is frequently associated with a similar transformation of the liver, spleen, and intestinal mucous mem- brane. The nature of this waxy degeneration of tissue is unknown, although probably it is some change in the chemical compositi'on of the structure affected, whereby it is rendered albuminoid. It is in no way amyloid, as previously pointed out (p. 250). But whatever be the es- sential nature of this peculiar degeneration, there can be little doubt that the waxy tissues are rendered more permeable by fluids, and hence the excessive discharge of urine and of matter from the intestinal mucous membrane when so affected. (Cases CLXXXVI. to CXC.) The Fatty Form.—This, as we have seen, may be a result of in- flammation, but it is not unfre- ^ quently produced independent of it. Here, again, the progress of the disease is chronic, is not so frequently associated with scrofula and tubercle, but occurs rather in individuals more ad- vanced in life, suffering from cardiac and bronchitic disorders, or who are addicted to intem- perance. It is also frequently associated with fatty degenera- tion of the heart and liver. Fig. 476. Dropsy and persistent albuminuria are constant symptoms, and the sediment is haded with casts of the tubes containing oil granules (fatty casts) and granule cells. Fig. 475. Waxy degeneration of a Malpighian body, with a few granule cells.— (Wedl\ 300 diam. Fig. 416. Structures in a fatty kidney, a and b, Tubes filled with fatty granules, havinf in one of them the transparent basement membrane visible c, Transverse section of a similar tube, rf, Fatty epithelium of he tubes e, Amorphous fatty matter in the tubes. /, Crystals of uric acid in a tubule.-( Wedl.) 350 dian. 822 DISEASES OF THE GENITO-URINARY SYSTEM. On examining the kidneys of individuals who have died of this form of the disease, we observe the tubes more or less obstructed by fatty granules, which have gradually accumulated in the epithelial cells of the tubes. These separate, and even burst, liberating their contents and in this way obstruct the tubes, and compress the secreting and surrounding textures (Fig. 476, a and b). Gradually the vessels are so compressed, that the organ affected looks bloodless, and though, on the whole, enlarged, is of a light fawn or dirty white color. The fibrous texture is occasionally hypertrophied, causing contractions round the convoluted tubes, thus producing irregularities on the surface. Occasionally, also, large accumulations of the fatty granules take place, causing the tubes to burst, and presenting to the naked eye light fawn- colored spots or granulations, more or less numerous, which are scattered over and through the cortical substance. It is easy to conceive how such accumulations of fat, and consequent pressure and obstruction, must at length so interfere with the kidneys, as to be incompatible with #the performance of their functions (Case CXCI.) On scraping the surface of a fatty kidney, and adding a drop of water, we are enabled #to see, under a magnifying power, fragments and cells such are given Figs. 476, 477. They exhibit portions of uriniferous tubes loaded with free fat granules and epithelial cells, Fig. 477. also containing similar fat granules. On making a thin section of a fatty kidney, we not unfrequently see the Fig. 478. Fig. 479. tubes in situ loaded with similar granules, and the fibrous tissue so iu- Fig. 477. Portion of fatty tube, with fatty epithelial cells, scraped from the sur face of a fatty kidney. Fig. 478. Longitudinal section of a fatty kidney, showing the tubes loaded with fatty granules. Fig. 479. Transverse section to the former one, (i.) Malpighian body.— (Christi- son.) 250 diam. BRIGHT'S DISEASE. 823 creased and thickened between them, as to occasion a lesion identical in many respects with the so-called cirrhosis of the liver, to which an atrophied and granular kidney is strictly analogous. Sections of the cortical substance of such kidneys are represented Figs. 478, 479. The above is a condensed description of what appears to me the three pathological forms of Bright's disease of the kidney. These lesions, although they are met with separately and distinct, may, however, be more or less conjoined. One part of a kidney may be congested or inflamed, whilst another is fatty; or we may have the fatty and waxy conditions united together. It is only in this way that we can account for the various shades of alteration which the kidney may at different times present during the continuance of persistent albumin- uria with dropsy. All these alterations, by interfering with the secret- ing functions of the cells, more or less disorder the excretory power of the kidneys, and, if continued, ultimately tend to overload the blood with the effete elements which ought to be discharged with the urine. At the same time, by causing more or less congestion of the vessels, or by pressure on the Malpighian bodies, and obstruction of the tubules, a serous effusion takes place, the albumen of which, passing into the urine, communicates to it that property of coagulability which constitutes its pathognomonic character. Diagnosis of B'right's Disease. The diagnosis of Bright's disease of the kidney is dependent on three kinds of observation :—1st, Symptoms; 2d, Chemical—and 3d, Microscopical—examination of the urine. 1. Diagnostic Symptoms.—In the acute forms, pain in the lumbar regions, high-colored urine, and other indications of nephritis, followed by dropsy; and in the more chronic forms, the occurrence of dropsy, frequently without the local renal symptoms, are the chief diagnostic symptoms. A constant desire to pass urine, and the passage of a large quantity of that fluid should also excite apprehension. But these symptoms must always be very vague until, by a chemical examination of the urine, the presence of albumen is determined. Chemical Examination of the Urine.—In testing the urine, you should be careful to employ both heat and nitric acid. Heat alone frequently separates earthy salts, which to the eye may resemble a slight cloud of albumen; and nitric acid alone frequently throws down a precipitate of uric acid, where urate of ammonia is in excess. But if the coagulum produced by heat also resist the action of nitric acid, we may be pretty sure that the urine contains albumen. The mere presence of albumen in the urine does not constitute Bright's disease. It may accompany cystitis or haematuria,—may follow the action of a blister affecting the kidneys, or result from mercurialism, errors in diet, or con- firmed dyspepsia. In all such cases, however, it is temporary, and does not present the diagnostic character of persistence. 824 DISEASES OF THE GENITO-URINARY SYSTEM. Microscopical Examination of the Urine.—The method I have found best for determining the form and structure of the organic matter dis- charged in the urine, is to allow the fluid to repose for twelve hours then pour off the supernatant liquid, and put the turbid sediment into a test-tube. Allow this to repose for another twelve hours, when the concentrated precipitate containing the organic matters collects at the bottom, and can now easily be brought into the field of the microscope. Or some ounces of the urine may be put into a conical glass, like an ale glass, and the precipitate allowed to deposit itself, as recommended by Dr. Johnson. From thence it can easily be obtained by pouring off the supernatant fluid, or by removing the sediment with a pipette for microscopic examination. The objects so brought into view are various, comprising different salts, cells, fungi, and casts of tubes (see pp. 103 to 107, and Figs. 102 to 114), the discrimination of which necessitates a knowledge of histology. The diagnostic elements, however, in Bright's disease, may be considered to be the separated casts of the tubuli uriniferi. These are of four kinds. 1. Exudative Casts.—These casts consist of the coagulated exuda- tion, or fibrin, which, in the inflammatory form, is poured into the tubes, so as to present a mould of their interior. They are analogous to similar casts which occur in the minute bronchi, *in all cases of pneumonia, and are recognised under the microscope by their uniform molecular structure. They mostly occur in acute cases, are frequently associated with blood corpuscles, and not unfrequently with desquamative casts and epithelial cells. Figs. 108 b, and 480. 2. Desquamative Casts.—These casts consist of mass- es of the epithelium lining the tubules, sometimes closely aggregated together side by side, at others ag- glutinated by means of the molecular exudation former- ly alluded to. They result from a separation of the lining cell membrane from the interior of the tube, in patches of greater or less extent and may be associated in acute cases with exudations, and in chronic cases with the fatty or waxy ^ ig transformations next to be mentioned.— See Figs. 108 a, p. 105, and 481. 3. Fatty Casts.—These casts consist also of patches r\ Fig. 480. of epithelium, which, however, have previously under- gone the fatty transformation, by the accumulation of a greater or less number of fatty granules in their cells. Occasionally the cells burst and fill the tubes with fatty granules, among which no epithelium can be distin- guished.—(See Fig. 109, p. 105, and Fig. 476.) At Kg.48i. others the cells are less changed, the fatty accumulation as it were only commencing, as in Fig. 482. These fatty casts are often associated with fragments of desquamative ones, with a few cells, more or less fatty, and frequently with the next kind of cast to be noticed (Fig. 482). Waxy Casts.—These casts present an exceedingly diaphanous and 480. Exudative casts with epithelial cell and mass of coagulated exudation. 481. Desquamative casts with blood corpuscles, naked nuclei, and cells. BRIGHT'S DISEASE. 825 structureless substance, which, according to Dr. Johnson, is secreted by the basement membrane, after the destruction of its epithelial cells. But may it not consist of the basement membrane itself which has undergone some chemical transformation, the nature of which has yet to be ascertained ? The waxy are frequently associated with the two kinds of casts last described, but especially with the fatty ones (Figs. 482, 483). Not unfrequently all stages of transformation may be seen in the same demonstration, between one tube containing epithelial cells, more or less fatty, and another, which being empty, presents the translucent or waxy appearance. (Figs. 476, 483.) The exact signification of all these various kinds of casts has yet to be fully determined by clinical investigation. But it appears to me that the exudative casts indicate the most acute form of lesion—the desqua- mative a sub-acute, the fatty a chronic lesion, and the waxy a lesion destructive of the tubular textures. But as all these different changes may be going on in the kidney at the same moment, so we may find these various casts mingled with one another in various proportions, combined with other structural elements. The predominance in number of one kind of cast over another, will, however, serve to indicate to the pathologist, with tolerable correctness, the nature of the change which is going on in the renal organs. They undergo great variety in size, often being much smaller than any kind of uriniferous tubes, a circum- stance indicating considerable contraction of their calibres. Treatment of Bright's Disease. The acute forms of Bright's disease should be combated externally by cupping over the loins, and warm fomentations—internally by diaphoretics, and later by diuretics. I have seldom found it necessary to have recourse to general bleeding, and then only as a palliative to relieve pulmonary congestion. The chronic forms, in addition to appro- priate remedies, require attention to diet and exercise. ^ A non-fatty diet is evidently indicated in the fatty degeneration of the kidney. Exercise, change of air, and sea voyages are also beneficial. Care also should be taken that the surface be kept warm, and cutaneous transpiration favored. The complications and sequelae must be managed according to circumstances, and the general indications special to individual diseases. In this place I shall only allude to the effects of two classes of remedies, namely, diaphoretics and diuretics. Diaphoretics.—The connection which necessarily exists between the kidneys and the skin as excretory organs, is well known. In health, Fig. 482. Fatty casts with granule cell. Fig. 483. Waxy casts of various sizes. 826 DISEASES OF THE GENITO-URINARY SYSTEM. impeded function in the one, is to a certain extent, compensated for by increased function in the other ; and diseases in the skin, especially scar- latina, or other causes which tend to check cutaneous transpiration, are peculiarly liable to induce renal disorders. Such being the case, it seems highly judicious, in our efforts to cure, to excite, by all means in our power, the functions of the skin in cases of Bright's disease of the kidney ; and with this view, Dover's powder, keeping the surface warm, hot air baths, warm water baths, and a warm climate, are among the means which have been proved to be most useful. They are more especially indicated in the waxy form of the urine with increased amount of urine and slight dropsy. When, however, the urine is diminished, and dropsy a leading symptom, it frequently happens that these remedies are of no avail, and then we must have recourse to the next class of remedies. Diuretics.—It has been thought that in the acute inflammatory cases, where the kidney is more or less congested and loaded with exudation, diuretics, by stimulating the organs and exciting them to increased action, would add to, rather than diminish, the excitement. But when it is considered that the dropsy is induced by obstruction in the secreting tubes, which presents a mechanical obstacle to the outward flow of fluid, it seems probable that, by increasing that flow, the accumulations pro- ducing the obstruction may be washed out. Besides, by augmenting the amount of fluid from the Malpighian bodies through such tubes as still remain pervious, a compensation is frequently to be found for the dimin- ished flow which takes place in the obstructed ones. Certain it is, that I have given diuretics in all stages of the disease with the best effects, as soon as it became manifest that the remedies formerly alluded to were of no avail. Nor have I seen any bad results from the practice. Besides, in acute cases with diminution of urine and rapid dropsy, no other course is left open to us, as diaphoretics under such circumstances are seldom effectual. The whole class of diuretics may be tried in Bright's disease, in com- bination with other remedies; but the most valuable, so far as I have been able to determine, is the bitartrate of potass, which I have fre- quently seen to prodnce a most powerful effect, when every other had failed. The spongio-piline, saturated in a strong solution of infusion of digitalis applied externally, and digitaline administered internally in minute doses, both recommended by Dr. Christison, are useful. But here again I have seen the cream of tartar operate after both these had failed. Sometimes also, after it has been given without effect at an early period of the disease, it has succeeded remarkably well at a later one. Of this, the case of Herdmann (Case CLXXXII) is a remarkable example, which warrants our having recourse to the remedy again and again after certain intervals, should it not act. It is very possible that the casts which obstruct the tubes may be more loosened at one time than at another, and that a powerful diuretic may, in consequence, have a greater effect in washing out the obstructions and restoring the functions of the organs. At all events, I have rarely seen other diuretics succeed, when repeated attempts by means of the bitartrate of potass had failed. SECTION IX. DISEASES OF THE INTEGUMENTARY SYSTEM. Notwithstanding the great advances which have been made in our knowledge of diseases of the skin, it cannot be denied that very inexact notions prevail regarding this class of disorders. I do not here allude to the eruptive fevers which, from their frequency and danger, necessarily demand the attention of every professional man, so much as to the lighter and more chronic disorders to which the skin is subject. Ignorance, however, here, although it seldom occasions danger to human life, pro- duces great inconveniences, exasperates the progress of other maladies, renders life miserable, and frequently destroys those social relations and ties which constitute happiness. A lady was seized with an eruption on the genital organs, which rendered the slightest contact unbearable. Her husband suspected that she labored under syphilis, and accused her of infidelity. A medical man, who was consulted, pronounced her disease venereal—a separation took place between the parties; the lady always maintaining her inno- cence, but anxious to escape the unfounded suspicions and ill-treatment of her husband. Mercury and an anti-venereal treatment was continued for some time, but the disease increased in intensity. At length another physician, skilled in the diagnosis of skin diseases, was consulted, who pronounced it to be an eczema rubrum, quite unconnected with syphilis; and on the application of appropriate remedies, a speedy cure confirmed his diagnosis. A lady in the country sent one of her servants into town, to obtain advice for an eruption which had broken out on her body, and which she was afraid might be communicated to her children. The practitioner consulted was much puzzled, and asked me to see the patient, who, ac- cording to him, was laboring under a rare form of skin disease. I found a herpes zoster extending round one half the trunk, and told him it would disappear spontaneously in a few days, which it did. Nothing is more common in practice than to meet with cases among servants, where prurigo has been mistaken for itch, causing great alarm to the family, and much injury to the servant. The various diseases of the scalp also are continually confounded together. Indeed, examples might easily be accumulated, proving the inconvenience which an un- acquaintance with skin diseases may occasion both to patient and practi- tioner. A young medical man is especially^ liable to be consulted in cases of trifling skin eruptions; and nothing is so likely to establish his credit, as the ready diagnosis and skilful management of such disorders, 828 DISEASES OF THE INTEGUMENTARY SYSTEM. especially when (as frequently happens) they have been of long standing, and baffled the efforts of older practitioners. Conceiving, then, that this subject deserves more careful consideration than it usually meets with in a clinical course, I propose directing your attention to the classification general diagnosis, and treatment of these disorders as an introduction to the study of individual cases in the wards. CLASSIFICATION OF SKIN DISEASES. Skin diseases are so various in appearance and in their nature, that many experienced practitioners have endeavored to facilitate their study by arranging them in groups. There are three kinds of classifications which deserve notice—1st, The artificial classification of Willan, Bateman, and others; 2d, The natural arrangement of Alibert and others; and 3d, A pathological arrangement founded on the supposed morbid lesions. Of these, the best, and the one which most facilitates the study of cutaneous diseases, is certainly that of Willan. No doubt it has its faults and inconveniences, but many of them have been removed by Biett. This classification is founded upon the character presented by the erup- tion, which, when once known, determines the disease. It is an old saying, that it is much easier to play the critic and to find fault, than to construct something better. This remark may be well applied to those who have ventured to set aside the principles on which Willan's arrange- ment is founded, and to bring forward others. No natural classification can ever be followed by the student, as it presupposes a considerable knowledge of the subject. The pathological arrangement again is decidedly faulty. The morbid anatomy and pathology of many skin diseases are unknown; how, then, can we found a classification upon them ? Indeed, the very foundation on which such classifications are based, is continually undergoing changes as pathology advances. On the whole, therefore, the arrangement best suited to the student and for practical purposes is that of Willan and Bateman, with the modi- fications subsequently to be noticed. Definitions.—Before we can proceed to refer any particular disease to its appropriate class, we must be acquainted with the characteristic appearances which distinguish the different orders. They are as fol- lows :— 1. Exanthema (Rash).—Variously-formed, irregular-sized, superficial red patches, which disappear under pressure, and terminate in des- quamation. 2. Vesicida (Vesicle).—A small, acuminated, or orbicular elevation of the cuticle, containing lymph, which, at first clear and colorless, be- comes often opaque or pearl-colored. It is succeeded either by scurf or a laminated scab. 3. Bulla (Bleb).—This differs from the vesicle in its size, a large portion of the cuticle being detached from the skin by the interposition of a watery fluid, usually transparent. 4. Pustul-a (Pustule).—A circumscribed elevation of the cuticle, con- CLASSIFICATION OF SKIN DISEASES. 829 taming pus. It is succeeded by an elevated scab, which may or may not be followed by a cicatrix. 5. Papula (Pimple).—A small, solid, acuminated elevation of the cuticle, in appearance an enlarged papilla of the skin, commonly termi- natino- in scurf, and sometimes, though seldom, in slight ulceration of its summit. 6. Squama (Scale).—A lamina of morbid cuticle, hard, thickened, whitish, and opaque, covering either small papular red elevations, or larger deep-red, dry surfaces. 7. Tuberculum (Tubercle).—A small hard, indolent, primary eleva- tion of the skin, sometimes suppurating partially, sometimes ulcerating at its summit. 8. Macula (Spot).—A permanent discoloration of some portion of the skin, often with a change of its structure. These stains may be white or dark-colored. The different appearances thus described characterise the eight orders of Willan and Bateman—viz., 1. Exanthemata; 2. Vesiculae; 3. Bullae ; 4. Pustuke; 5. Papulae; 6. Squamae; 7. Tubercula; 8. Maculae. The principal modifications made by Biett consist in removing from these groups certain diseases which have no affinity with them, and forming them into extra orders of themselves. Thus he makes altogether fifteen orders, as seen in the following classification given by his pupils Schedel and Cazenave, which also indicate the subdivisions into which each order is divided :— Order I.—Exanthemata. Rubeola. Scarlatina. Erythema. Erysipelas. Roseola. Urticaria. Order II.— Vesiculce. Eczema. Herpes. Scabies. Miliaria. Varicella. Order III.—Bailee. Pemphigus. Rupia. Order IV.—Pustules. Variola. Vaccinia. Ecthyma. Impetigo. Acne. Mentagra. Porrigo. Equinia. Order V.—Papula. Lichen. Prurigo. Order VI.—Squamce. Psoriasis. Pityriasis. Ichthyosis. Order VII.—Tubercula. Lepra Tuberculosa. Lupus. Molluscum. Framboesia. Cheloidea. Order VIII.—Macula;. Lentigo. Ephelides. Nsevi and Vintiligo. Order IX.—Purpura. " X.—Pellagra. " XI.—Radesyge. " XII.—Lepra Astra- chanica. " Xin.—The Aleppo Evil, or Malum Alepporum. " XIV.—Elephantiasis Arabica. " XV.—Syphilids or Syphilitic Erup- tions. Even this classification is very complicated, and appears to me to admit of still further modifications, which will render the subject more simple and practical at the bed-side. I shall point out to you, in the first instance, the reasons which have induced me to make these modifi- cations, and then give, in a tabular form, the classification which we shall in future adopt. In the orders Exanthemata and PustuU we find several diseases which are characterised by excessive fever, so that they have long been spoken of under the term of eruptive fevers, as well as under that of febrile eruptions. With them, in short, fever is the characteristic, and 830 DISEASES OF THE INTEGUMENTARY SYSTEM. they are influenced by laws of a peculiar character, altogether different from those which regulate the production of other cutaneous affections. I propose, then, to remove these disorders from the category of skin dis- eases altogether, and to leave only three in the first order, namely, ery- thema, roseola, and urticaria. I am aware that, strictly speaking, these may be accompanied by slight fever, which may also occur in several other skin diseases. But I do not pretend to form a classification which is perfect, or even pathological, but one which some experience in the teaching of these diseases has convinced me is useful and practical for the student. _ In the order Vesiculce we find five diseases. I propose cutting out miliaria, as being very unimportant, and a trifling sequela of fevers. Varicella I believe to be a modified small-pox, and I omit it for the same reasons as I do variola. Scabies, on the other hand, though dependent upon the presence of an insect, the Acarus Scabiei, presents such distinct characters as to warrant its retention. I propose expunging the order Bulla; altogether. We find in it two diseases. The first of these, pemphigus or pompholyx, is a vesicular dis- ease in every point, appearing sometimes in successive crops, and form- ing a laminated scab. Kupia, on the other hand, is evidently a pustular disease, forming a prominent scab, producing ulceration, and leaving a cicatrix. I shall therefore add pemphigus to the order vesiculje, and rupia to that of the pustulae. From the Pustulee, for the reasons formerly stated, I expunge variola, vaccinia, and equinia. Mentagra, so far as I have been able to study it in this country, has always consisted of eczema or impetigo on the chin of the male. In syphilitic cases it is more or less tubercular, and it has been described also as consisting of a vegetable parasite. Although I have never seen the appearance figured by Cazenave (Plate 10), I can understand that such a mentagra might really consist of vegetable fungi. At all events, mentagra is not a special pustular disease. Porrigo means any eruption on the head, whether vesicular, pustular, or squamous. Favus, to which it has long been applied, is undoubtedly a parasite, and ought, with others of a like nature, to constitute a distinct class. More- over, it is neither vesicular nor pustular. Hence the class of pustulae will with us contain only impetigo, ecthyma, acne, and rupia. The orders Papida and Squama remain the game. The strophulus of many English writers is certainly only lichen occurring in the child; and what has been called lepra, as distinguished from psoriasis, is the latter disease presenting an annular form. From the class Tubercula I cut out frambcesia, as being a disease un- known in this country, together with cheloidea, which, as I understand it. means either cancer or tubercle of the skin. As regards the order Macula, I place purpura in it, as did Willan, because, although sometimes it may depend on constitutional causes of an obscure nature, and at others be allied to scurvy, it still, in an arbi- trary classification of this kind, constitutes an undoubted spot or macula. All the other orders of Biett I shall take the liberty of expunging— pellagra, lepra Astrachanica, and malum Alepporum, are unknown in this country. I agree with Hebra, in thinking that Radesyge is only a modi- DIAGNOSIS OF SKIN DISEASES. 831 fied form of lupus. The elephantiasis Arabica is an hypertrophy of the areolar tissue or chorion, and belongs more to the subject of fibrous growths than that of skin diseases. Syphilitic diseases I do not regard as a distinct order, but as any of the ordinary skin affections, more or less modified by a peculiar state of the constitution. Whilst I have cut out many diseases from the eight orders originally established by Willan, and subsequently modified by Biett, I find it ne- cessary to add two orders, which the advance of pathology and histology shows ought to be considered apart. I allude to those which depend on the presence of parasitic animals and plants, and which may be called respectively Dermatozoa and Dermatophyta. It has now been shown by M. Bourguignon, that scabies is dependent on the presence of an acarus, but that the insect is only indirectly the cause of the eruption. Hence I put acarus among the dermatozoa, although it certainly forms, when present, a constituent of itch. Among the dermatophytes will be placed favus and mentagra—both removed from the class pustulae. Other dis- eases, such as plica Polonica, and pityriasis, have been considered as parasitic; but the former is unknown in this country, and the latter, when it presents epiphytes among the scales, constitutes a form of favus. The classification, then, we shall in future adopt is as follows: Order I.—Exanthemata. Order IV.—Papulce. Nsevi. Erythema. Lichen. Purpura. Roseola. Prurigo. Order VIII.—Dermatozoa. Urticaria. Order V.—Squamce. Entozoon folliculo- Order II.— Vesiculce. Psoriasis. rum. Eczema. Pityriasis. Acarus. Herpes. Ichthyosis. Pediculus. Scabies. Order VI.—Tubercula. Order IX.—Dermatophyta. Pemphigus. Lepra Tuberculosa. Achorion Schonleinii Order III.—Pustulae. Lupus. (Favus). Impetigo. Molluscum. Achorion Grubii Ecthyma. Order VI.—Macula;. (Mentagra).* Acne. Lentigo. Rupia. Ephelides. DIAGNOSIS OF SKIN DISEASES. The recognition of skin diseases, and the separating of one class from another, is of essential importance to a proper treatment. On this point I fully agree with a writer, who says, " The treatment of a great many cutaneous diseases is but of secondary importance compared with their differential diagnosis. Many of them will get well without any treat- ment, provided they are allowed to pursue their natural course; and, on the contrary, a mild and simple eruption, by being mistaken, from a similarity of external appearance, for one of a severe or rebellious char- * It has been objected to the words porrigophyte and mentagrapbyte, introduced by Gruby, that they are unclassical; and as the celebrated botanist Link, after care- fully examining these vegetations, has described the former as a new genus, under the head of Achorion (from achor, the old term given to a favus crust by Willan), I have thought it best to adopt that term. To mark the variety in favus, he has added the name of its discoverer, Schonlein ; and I have ventured, at all events provisionally, to distinguish the one described as existing in mentagra, by adding to it also that of its discoverer, Gruby. 832 DISEASES OF THE INTEGUMENTARY SYSTEM. acter, and treated accordingly, may be aggravated and prolonged for an indefinite period."—(Burgess.) This differential diagnosis, however to the inexperienced, is a matter of great difficulty, because not only is con- siderable tact generally necessary to discover the original element each disease presents, such as rash, vesicle, pustule, scale, and so on- but often this is impossible. Under such circumstances the diagnosis is fre- quently derived from the scab, or other appearances presented, such as the cicatrix. The whole subject has been rendered very confused and complicated by systematic writers, who have often given different names to the same disease, or unnecessarily divided them into forms and va- rieties. I advise you not to pay any attention to these forms and varie- ties for the present, and to confine your efforts only to the detection of the diseases enumerated in the table under each order; and with a view of facilitating your endeavors, the following short diagnostic characters and definitions should be attended to. I. Exanthemata. 1. Erythema.—A slight continuous redness of the skin in patches of various shapes and sizes. 2. Roseola.—Circumscribed rose-red patches, of a circular, serrated, or annular form. 3. Urticaria.—Prominent red patches of irregular form, the centre of which is often paler than the surrounding skin. II. Vesicui^e. Eczema.—Very minute vesicles in patches, presenting a shining ap- pearance, yielding a fluid which dries into a laminated or furfuraceous crust. The skin is a bright red color. Herpes.—Clusters of vesicles, varying in size from a millet seed to that of a pea, surrounded by a bright red areola. They yield a fluid which dries into a thin incrustation, that drops off between the eighth and fifteenth day. Scabies.—Isolated vesicles of an acuminated form, commonly seated between the fingers and flexor surfaces of the arms and abdomen—never on the face. Pemphigus.—Large vesicles or blebs (bullae) surrounded by an ery- thematous circle, the fluid of which forms, when dry, a laminated crust. When chronic, they appear in successive crops, and the disease is called pompholyx. III. Pustulae. Impetigo.—Small pustules, commonly occurring in groups, and form- ing an elevated crust. Ecthyma.—Large isolated pustules, depressed or umbilicated in the centre, and leaving a cicatrix. Acne.—Isolated pustules situated on a hardened base, which form and disappear slowly. They only occur on the face and shoulders. Rupia.—Large pustules, followed by thick prominent crusts, and pro- ducing ulcerations of various depths. DIAGNOSIS OF SKIN DISEASES. 833 IV. Papulae. Lichen.—Minute papulae occurring in clusters or patches. Prurigo.—Larger and isolated papulae generally seated on the exten- sor surfaces of the body. V. Squamae. Psoriasis.—Whitish laminated scales slightly raised above the red- dened surface of the skin. Lepra is psoriasis occurring in rings. Pityriasis.—Very minute scales, like those of bran, seated on a red- dened surface. Ichthyosis.—Induration of the epidermis, and formation of square or angular prominences, not seated on a reddened surface. VI. Tdbeecula. Lepra Tuberculosa.—(Elephantiasis of the Greeks).—Tubercles vary- ing in size, preceded by erythema and increased sensibility of the skin, and followed by ulceration of their summits. Lupus.—Induration or tubercular swelling of the skin, which may or may not ulcerate. In the former case, ulceration may occur at the sum- mit or at the base of the tubercles, and frequently extends in the form of a circle more or less complete. Molluscum.—Pedunculated, globular, or flatfish tubercles, accom- panied by no erythema or increased sensibility, occurring in groups. They are filled with atheromatous matter. VII. Macule. Lentigo or Freckle.—Brownish-yellow or fawn-colored spots on the face, bosom, hands, or neck. Ephelis.—Large patches of a yellowish-brown color, accompanied by slight desquamation of the cuticle. JVeevi or Moles.—Spots of various colors or forms, sometimes elevated above the skin. They are congenital. Purpura.—Red or elaret-colored spots or patches, which do not dis- appear under pressure of the finger. VIII. Dermatozoa. These minute animals require a lens of considerable power to ascer- tain their characters, which need not be particularised here, as they will be subsequently described and figured. (See p. 830, et seq.) IX. Dermatophyta. These minute plants require a high magnifying power to distinguish them with exactitude. But they communicate peculiar characters to certain cutaneous diseases, as follows'. Favus.—Bright yellow, umbiiicated crusts, surrounding individual 53 834 DISEASES OF THE INTEGUMENTARY SYSTEM. hairs, which agglomerate together to form an elevated friable crust, of a peculiar musty or mousey smell. Mentagra.—Grayish or yellowish dry crusts, of irregular form, origi- nating in the hair follicles of the beard. In forming your diagnosis, therefore, you will be guided principally by three characters :—1st, The primitive and essential appearance__that is, whether a rash, vesicle, pustule, and so on. 2d, The crust—whether laminated or prominent, composed of epidermis only, etc. 3d, Ulcera- tion,—whether present or absent; and if so, the kind of cicatrix. These and other characters I shall point out at the bed-side, so as to familiarise you with their appearances. You will remember that the classification formed by Willan is wholly artificial. It is like the Linnaean classification of plants. The difficulty for the learner is to recognise the essential character, the more so as many diseases pass through various stages before this is formed. Thus herpes presents—1st, a rash; 2d, papules ; 3d, vesicles ; 4th, pustules; yet the disease is considered vesicular. Ectbyma passes through the same stages, yet it is considered pustular. In the vesicular disease, however, the crust is laminated,—in the pustular, it is more or less prominent. Again, it not unfrequently happens that two or more diseases are combined together in one eruption. Thus it is very common to meet eczema and impetigo combined, when the disease is called Eczema impeti- qinodes. Favus occasionally causes considerable irritation, producing a pustular or impetiginous margin around it. The vesicles of scabies are often accompanied by the pustules of ecthyma, and so on. In very chronic skin diseases, it may happen that it is impossible to say what the original disorder was, whether vesicular, pustular, scaly, or papular. In such cases the skin assumes a red color, the dermis is thickened, the epidermis rough and indurated, and a morbid state is oc- casioned, in which all trace of the original disease is lost, and what remains is a condition common to various disorders. As regards varieties, little need be said, and as I formerly stated, I advise you to postpone their study until you are acquainted with the diseases themselves. Even then an acquaintance with them is of secon- dary importance. These varieties have been formed on account of the most varied circumstances, such as,—1st, Duration, most of them may be acute or chronic; 2d, Obstinacy, the terms fugax, inveterata, acrius, etc.; 3d, Intensity, hence the terms mitis, maligna, etc.; 4th, Situa- tion, hence the terms capitis, facialis, labialis, palmaris, etc.; 5th, Form, hence the terms circinatus, scutulata, iris, gyrata, larvalis,figu- rata, tuberosa, guttata, etc.; 6th, Constitution, hence the terms cachec- tica, scorbutica, syphilitica, etc.; 7th, Age, hence the terms infantilis, senilis, etc.; 8th, Color, hence the terms album, nigrum, rubrum, versicolor, etc.; 9th, Density, hence the terms sparsa, diffusa, concen- tricus, etc.; 10th, Feel, hence the terms lave, indurata ; 11th, Sensa- tion produced, hence the terms formicans,pruritus, urticans, etc.; 12th, Geographical distribution, hence the terms tropicus, Mgyptiana, Nor- wegiana, etc. DIAGNOSIS of skin diseases. 835 PoRRIGO. There was a period in the history of skin diseases when they were arranged in two great divisions—viz., those affecting the scalp, and those affecting the rest of the cutaneous surface. All the disorders compre- hended in the first of these divisions received the name of Porrigo, a word said by some to be derived from porrum, on account of the scales or concretions of the scalp resembling the layers of an onion; by others it is derived from porrigo, to spread. Willan described six kinds of Por- rigo, viz., P. larvalis, P. furfurans, P. scutulata, P. favosa, P. lupi- nosa, and P. decalvans. It is now ascertained that none of these dis- eases are necessarily peculiar to the scalp,—and that, although they are more or less modified by being connected with and affecting the hairs of that region, they may also occur on other parts of the skin. There can be little doubt, however, that the employment of the term Porrigo, as well as the corresponding word Teigne in France, has thrown great con- fusion over the subject of eruptions on the scalp. But, as this term is still in pretty general use, it will be well to explain to you what diseases these different kinds of Porrigo really are. Porrigo larvalis (larva, a mask) is really Impetigo, or Eczema impe- tiginodes, of the scalp. The former is recognised by crusts more or less prominent or nodulated; the latter, by the circumstance that, in addition to these nodules, there is between them a laminated or brittle crust, spread more or less equally over the surface. They are both very com- mon in infants and children; and the disease sometimes extends over the face, concealing the features, hence the term larvalis. A very charac- teristic representation of Ii petigo capitis is given in Willan and Bate- man, Plate xli., erroneously called Porrigo favosa. (See also the disease on the face, ibid., Plate xxxvii. ; Alibert, Planches 13 and 15.) Porrigo furfurans {furfur, bran) is really Pityriasis of the scalp, although Psoriasis of that region has also received the same appellation. There is also a peculiar form of Eczema, or Eczema impetiginodes, in which the crust is friable, and breaks up, or crumbles into minute,frag- ments, to which the term furfurans has been erroneously applied. The true Porrigo furfurans (Pityriasis) is well represented, Willan and Bate- man, Plate xxxviii.; Alibert, Planches 14 and 15. It is often a form of favus. (See Favus.) Porrigo scutulata (scutulum, a small shield).—The nature of this dis- ease has been much disputed. By some it is said to be Favus (Erasmus Wilson), by others a form of Herpes (Cazenave). The disease is de- scribed by Willan and Bateman, and more recently by Burgess, as con- sisting of oval or rounded, slightly elevated patches, covered with furfur, and having stunted or filamentous hair projecting from the sur- face. It is a form of skin eruption exceedingly rare in Edinburgh. It seems to be represented, Willan and Bateman, Plate xxxix.; Willis (Trichosis scutulata). Porrigo favosa (favus, a honeycomb) is a disease, the true nature of 836 diseases of the integumentary system. which has been only lately determined. It consists essentially of an exudation on the skin, in which fungi or phytaceous plants grow. Eound, isolated, bright yellow crusts are formed, which, when compressed toge- ther, assume an hexagonal shape—hence the term favosa, It is well represented, Willis (Trichosis lupinosa); Erasmus Wilson, Fasciculus I., Alibert, Planche 17. Porrigo lupinosa (lupinum, the lupine).—This is the same disease as the last. The round or oval crusts, when isolated and at an early stage, present a concavity and form resembling that of the lupine seed—hence its name. Porrigo decalvans (calvus, bald).—Baldness is so common among the aged that it can scarcely be called a disease; but when it occurs in young persons, and is circumscribed, it constitutes the Porrigo decalvans of Willan. It is said by Gruby to depend on a vegetable parasite grow- ing in the hair. It is well represented, Willan and Bateman, Plate xl.; Willis (Trichosis decalvans). From this analysis of the different kinds of the so-called Porrigo, you observe that there is nothing peculiar with regard to them. With the exception of baldness, none essentially belong to the hairy scalp. . True favus is far more common on the head than elsewhere ; but I have fre- quently seen it on various parts of the cutaneous surface, and occasion- ally on the cheeks or shoulders, without being on the scalp at all. It follows that, instead of the term Porrigo, you should designate the disease as Eczema, Impetigo, Pityriasis, Psoriasis, or Favus of the scalp, as the case may be. Notwithstanding I have endeavored to place this subject before you in as simple and uncomplicated a form as possible, I am conscious that at first you will still experience considerable difficulty in the diagnosis of skin affections. This can only be removed by practical experience at the bed-side, and by constantly exercising your powers of observation in detecting the essential elements which their varied forms present. At the same time, I think the modified classification and short characters I have given, will materially assist your studies in this important depart- ment of practical medicine. It must be remembered, however, that they only refer to those cutaneous diseases which you are liable to meet with in this country. Should you ever be called upon to practise in the tropics, or in other places where peculiar skin disorders prevail, it will, of course, be your duty to study them in an especial manner. Here, as they cannot be made the subject of clinical observation, they are alto- gether removed from our consideration. THE TREATMENT OF SKIN DISEASES. Since the addition of a ward for skin diseases to the clinical depart- ment of the Royal Infirmary, I have had ample opportunities of deter- mining what are the more common forms of cutaneous eruption met with the treatment of skin diseases. 837 in Edinburgh, and of trying various kinds of remedies. As the illus- tration of so many forms of integumentary disease by reports of cases is in this work impossible, I propose now to give a condensed account of the treatment I have found most successful. Exanthemata. Few case3 laboring under erythema, roseola, or urticaria, enter the Infirmary; and in such as occasionally present these eruptions during their residence there, the mildest remedies suffice for their removal. In the severer cases, a saturnine lotion to diminish local irritation, with a saline purgative, generally suffices for the cure. VESICULiE. Eczema is by far the most common disease met with, both in its acute and chronic forms. The local treatment I have found most effica- cious is that which I first recommended in 1849.* It consists in keep- ing the affected part moist, with lint or linen saturated in a very weak alkaline solution, consisting of 3 ss of the common carbonate of soda dissolved in a pint of water. For this purpose it is necessary to cover the moistened lint with oil silk, or gutta-percha sheeting, which should well overlap the lint below, so as to prevent evaporation. The usual effect is soon to remove all local irritation, and especially the itching or smarting so distressing to the patient. It also keeps the surface clean, and prevents the accumulation of those scabs and crusts which in them- selves often tend to keep up the disease. After a time, even the indu- rated parts begin to soften, the margins of the eruption lose their fiery red color, and merge into that of the healthy skin, and finally the whole surface assumes its normal character. In private practice, it is often a matter of great difficulty to secure a proper application of the lotion. Individuals are slow to accept the idea that constant moisture of the part is absolutely necessary for the treatment, and hence vigilant superintendence and frequent visits are requisite, in order to watch the progress of the case. Even in the hos- pital constant care is necessary, to see that nurses properly cover the eruption; and when, as sometimes happens, this task is given to the pa- tients themselves, it almost always fails. Then there are some portions of the surface which it is very difficult to keep moist and well eovered, such as the face and axillae. But, by carefully adapting lint and gutta- percha sheeting, attaching strings to the edges of the latter, so as to keep the whole in its place, I have never failed in ultimately carrying out my object. In the Infirmary I treat vesicular eruptions of the face in this way by means of a mask, having apertures for the eyes, nostrils, and mouth. If the eruption be very general, long soaking in slightly alkaline baths is useful. In addition to stating what I have found to be beneficial, it is im- portant to say what I have, on careful trial, ascertained to be useless or injurious. Perhaps no remedy is more generally employed in this and a variety of other skin diseases than citrine ointment—an applica- * Monthly Journal of Medical Science, August 1849. 838 diseases of the integumentary system. tion that I have always found to irritate and make eczematous eruptions worse. At the same time, there are some very chronic forms of the dis- ease which I have been told are cured by this preparation, but what these are I have never been able to ascertain. Indeed, all greasy appli- cations whatever, in acute cases, are useless, and the patients themselves say, are very " heating." I have tried the freezing process recommended by Dr. Arnott, but the salt of the frigorific mixture, and the cold itself has caused apparently so much agony, that I have been deterred from using it, especially when the emollient moist alkaline application is so efficacious. In some rebellious chronic cases I have occasionally found the oil of cade a useful remedy, and in others the oxide of zinc ointment. They are most beneficial after a prolonged use of the moist alkaline applica- tion. In the same way, friction with the hand or a soft flesh-brush fa- vors the disappearance of the chronic induration and vascularity of chronic eczema of the inferior extremities, which should be kept as much as possible in the recumbent position. These stimulating appli- cations, whilst useful in the very chronic and non-irritative forms of the disease, or to remove what an emollient treatment fails to accomplish, are most injurious in the acute forms. Herpes.—This disease generally runs its course in about fourteen days, and requires no treatment whatever further than an acetate of lead lotion to allay the smarting. It is not very eommon. Scabies occurs very frequently, and is cured by a host of remedies. A strong lather, made of common soft soap and warm water, twice a day, answers very well. The question with scabies, is not what remedy is useful, but which will cure it in the shortest period. The most exten- sive experience at St. Louis has shown, that the sulphur and alkaline, or Helmerinch's ointment, cures itch, on an average, in seven days. That sulphur, however, is not the active remedy, I have satisfied myself by experiment. Soft soap, as we have seen, which contains alkali, and even simple lard, if pains be taken to keep the parts constantly covered with it, will cure the disease as soon as sulphur ointment. I have tried the Stavesacre ointment, recommended by M. Bourguignon, in only a few cases, but found it to answer very well. Its superiority, however, over. other applications, I am not yet prepared to admit. (See Dermatozoa.) Pemphigus.—This is rather a rare disease, and when chronic, coming out in successive crops, is very rebellious. I have cured several acute, and some tolerably chronic cases, in from one to three weeks, by the weak alkaline wash, applied as in the case of eczema, combined with generous diet. Pustule. Impetigo.—This affection in all its forms is very common, and is best treated by the weak alkaline wash, exactly the same as in eczema. In the chronic forms which attack the chin of men, constituting one of the varieties of mentagra, the same treatment cures the most rebellious cases, if the moisture be constantly preserved. For this purpose the hair must be cautiously cut short with sharp scissors, and the razor care- fully avoided. If the side of the cheek covered by the whisker be THE TREATMENT OF SKIN DISEASES. 839 attacked, removal of the hair from thence also is essential to the treat- ment. A bag or covering accurately adapted to the part affected must be made of gutta-percha sheeting, and tied on with strings. This may be covered with a piece of black silk, to allow the individual to go about and carry on his usual occupations. In this way I have fre- quently seen chronic impetigo of the chin, of from eight to ten years' standing, which has resisted all kinds of ointments and heroic remedies, completely removed in a few weeks. But then the surface must be kept constantly moist, a circumstance requiring great care and determination on the part of the patient. When it becomes necessary to shave, flour and warm water, or paste, should be used, and not soap. Alkalies, applied from time to time only, as in the form of wash or soap, always irritate, although, when employed continuously, they are soothing. Ecthyma is not a common disease, and usually presents itself con- joined with Eczema or Impetigo, and is treated successfully in the same manner as those diseases. The E. cachecticum requires, in addition to the alkaline wash locally, a generous diet. Acne is a disease frequently requiring constitutional rather than local remedies. Although not uncommon in private, it is rare in hos- pital practice. Careful regulation of the diet, abstinence from wine and stimulating articles of food, watering-places, baths, etc. etc., constitute the appropriate treatment. Rupia.—This disease I have never seen occur but in individuals who have been subjected to the influence of mercurial poisoning. Hydriodate of potassium and tonic remedies, with careful avoidance of mercury in all its forms, is the general treatment I have found most successful. If the pustules be few in number, the scabs may be removed by poulticing, and the sores treated locally with water-dressing or red wash. But if they are numerous, great caution should be exercised in exposing so many ulcerated surfaces, and it is better to let the crusts remain. Papula. Lichen and Prurigo.—In both these affections, constant inunction with lard is as beneficial as constant moisture in the eczematous and impetiginous disorders. In the prurigo of aged persons, the Ung. Hyd. Precip. Alb. is a useful application, although the disease is not unfre- quently so rebellious as only to admit of palliation. The chronic papu- lar diseases often constitute the despair of the physician. Squam.e. Psoriasis, and that modification of it known as lepra, is a very com- mon disease, and has been uniformly treated by me externally with pitch ointment. I have satisfied myself, by careful trials, that it is the pitch applied to the part that is the beneficial agent, as I have given pitch pills and infusion of pitch largely internally, without benefit. With the hope of obtaining a less disagreeable remedy, I have frequently tried creasote, and naphtha ointment, and washes, but also without i 840 DISEASES OF THE INTEGUMENTARY SYSTEM. benefit. Lastly, I have caused simple lard to be rubbed in for a length- ened time, but without doing the slightest good. The oil of cade is occasionally useful, especially in psoriasis of the scalp. Internally, I give five drops of Fowler's solution, and as many of the tr. cantharidis. It is rare that the internal treatment alone produces any effect on a case of psoriasis of any standing. If a case resists this conjoined external and internal treatment, I have always found it incurable. Some years ago I carefully treated a series of cases internally with Donovan's solu- tion, without producing the slightest benefit. True Pityriasis frequently disappears of itself. In chronic cases the treatment by pitch is useful, and sometimes the application of the Ung. Zinci Oxyd. or Ung. Hyd. Precip. Alb. The form of pityriasis that is dependent on a vegetable fungus is identical with favus. (See Favus.) Ichthyosis.—I have treated several chronic cases of ichthyosis. But while in some cases the skin has become a little softer from a course of pitch treatment, no permanent cure was effected. Tueercul^:. Lupus is the only kind of tubercular skin disease I have seen in the skin ward of the Infirmary, and that is pretty common. It is a constitutional disorder, and must be treated by cod-liver oil, and all those remedies useful for scrofula, of which it is a local manifestation. The external treatment is surgical, consisting of the occasional applica- tion of caustics, red lotion, water-dressing, ointments, etc., according to the appearance of the sore. I agree with Hebra in thinking lupus and the radesyge of the Norwegians to be the same disease. Many years ago I found lupus of the legs and thighs to exist among the fisher- women of Newhaven, who assisted their husbands in hauling in their boats, or who were accustomed to wade for any length of time in salt water. Macule. Lentigo I have never found to be benefited by any kind of treatment, local or general. It is evidently connected with season and the intensity of the sun's rays, as it often disappears in winter and returns in summer. Ephelis and Ncevi are alike incurable. Bronzing from exposure to the sun, as in hot climates^ frequently disappears on returning to a tem- perate latitude. Purpura is a, constitutional disorder, for the most part allied to scurvy. It consists of an alteration of the blood, with tendency to dis- integration of the colored corpuscles and diffusion of haematozine. Un- der such circumstances, ecchymoses occur in the skin, sometimes con- fined to round spots, varying in size, at others existing in patches. It is for the most part associated with weakness, and requires rest and time to permit absorption of the extravasated blood, conjoined with tonics, anti-scorbutics, and generous diet. In sea scurvy, lemon juice and fresh vegetables are the true remedies. (See Scorbutus.) Scalp diseases must be treated according as they depend on eczema, ■ THE TREATMENT OF SKIN DISEASES. 841 impetigo, psoriasis, or favus—in all cases first removing the crusts with poultices^ then keeping the head shaved, and, lastly, applying alkaline washes, pitch ointment, or oil, according to the directions formerly given. Ringworm is a disease I have never seen in Edinburgh, and of what it consists I am ignorant. Some writers apparently consider it to be favus, and others a form of herpes. On two or three occasions I have seen a scaly disease of the scalp, in the form of a ring—that is lepra, which I have cured by pitch ointment, or oil of cade. Dr. Andrew Wood in- formed me some time ago, that he banished it from the Heriot's Hos- pital school of this city by condensing on the eruption the fumes of coarse brown paper, and thus causing an empyrrheumatic oil, or kind of tar, to fall upon the part. This at one time led me to suppose that it might be a scaly disease, and a form of lepra or psoriasis. On the whole, I am inclined to think it a form of favus, which has commonly been mistaken for a scaly disease of the scalp. (See Favus.) So-called Syphilitic diseases of the skin are, in my opinion, the various disorders already alluded to, modified by occurring in individ- uals who have suffered for periods more or less long from the poisonous action of mercury. A longer time will be required for their cure, but the same remedies locally, conjoined with hydriodate of potassium in small doses, with bitter infusions, tonics, and a regulated diet, offer the best chance of success. The great difficulty in the treatment of skin diseases generally con- sists in their having been mismanaged in the early stages—a circum- stance I attribute to the little care with which, until a recent period, clinical students have studied them. Many chronic cases of eczema are continually coming under my notice, which, in their acute forms, have been treated by citrine ointment, or other irritating applications, that almost invariably exasperate the disorder. I shall not easily forget the case of one gentleman, covered all over with acute eczema, who had suffered excessive torture from its having been mistaken for psoriasis, and rubbed for some time with pitch ointment. In the same way I have seen a simple herpes, which would have readily got well if left to itself, converted into an ulcerated sore by the use of mercurial ointment. Nothing is more common than to confound chronic eczema of the scalp with favus, although the microscope furnishes us with the most exact means of diagnosis. I have seen one case in which a chronic eczema of the cheek was cut out by a surgeon, under the idea that the disease was malignant. I presume that acne must frequently have been mistaken for tubercular disease. In no other way can I account for some very dis- tressing cases, where the patients' faces have been painted over with but- ter of antimony. I need scarcely say, that the correct application of the remedies I have spoken of can only be secured by an accurate discrim- ination, in the first instance, of the diseases to which they are applicable. The general constitutional treatment in all these cases seldom de- mands aperient or lowering remedies except in young and robust indi- viduals with febrile symptoms. In the great majority of cases, cod- liver oil, good diet, and tonics are required. In a few instances sedatives, both locally and internally, are necessary to overcome exces- sive itchino- or irritation. These the judicious practitioner will readily 842 DISEASES OF THE INTEGUMENTARY SYSTEM. understand how to apply according to circumstances. Baths in all their various forms are useful in skin diseases, although, since I have applied a kind of constant local bath in the form of moist application. formerly alluded to (See Treatment of Eczema), they are comparatively seldom used by me in the Infirmary. The natural baths and mineral springs of watering-places in Great Britain, France, and Germany, are undoubtedly beneficial in appropriate chronic cases. DERMATOZOA. The skin may be attacked by certain animal parasites. Of these the pedicula, or lice, are too well known to need description. But we may shortly allude to the Acarus scabici, and the Entozoon follicu- lorum. Acarus Scabiei. This insect has been proved by the researches of M. Bourguignon* to be the undoubted cause of itch. The male is about a third smaller Fig. 486. than the female. He has suckers on two of his hind feet, and possesses on the abdominal surface genital organs, all of which characters are * Traite entomologique et pathologique de la gale de l'homme. 4to. Paris, 1852. Fig. 484. Dorsal surface of the female Acarus Scabiei. Fig. 485. Ventral surface of the same. Fig. 486. Ventral surface of the male Acarus.—(Bourguignon.) 100 diam. DERMATOZOA. 843 absent in the female. She, on the other hand, in addition to her size, and the negative marks alluded to, is characterised by the three kinds of horny spines which are scattered over the back. The suckers, or ambulacria, are organs of locomotion; the mandibles enable it to cut the epidermis, and extract fluid from the tissue, which passes through a delicate oesophagus, the internal termination of which is unknown, the body of the animal being apparently filled with an unorganized, very finely molecular pulp. A short delicate tube may also sometimes be observed at the anus—a supposed rectum. No respiratory apparatus can be discovered, although the creature may be seen to swallow minute bubbles of air, which pass down the oesophagus, and, like the nutritive juices, diffuse themselves through the interior. At all events, animal juice and air are both necessary to the life of the Acarus. The disease called scabies has been conclusively shown by M. Bourguignon to be entirely owing to the presence of the insect, and to be communicated from one person to another, eight times out of ten, by their sleeping together. The female seldom quits her burrow but at night, and if impregnated, not even then, unless disturbed mechani- cally, as by scratching. Once in motion, she crawls over the surface with great rapidity, and readily passes from one person to another, where the skins are in contact. Communication is not readily occa- sioned by holding the hands of those affected, or by coming in contact with them during the day. The disease cannot be communicated by inoculating with the serum of the vesicles, by the pus of the pustules, or by any principle contained in the dead body of the insect itself. Neither can the Acarus of one species of animal, as of the horse or sheep, inhabit the body of a different one. Still the disease is not purely local, inas- much as papular, vesicular, or pustular eruptions often occur in parts which the Acarus has not infested, so that they seem to originate from some cause independent of its mere presence. The Acarus has a predilection for youth and a tender skin, and has a hatred of hair bulbs. Hence why it frequents young persons more commonly than old ones, and why in children it occurs indis- criminately all over the body, while in adults it is most often found between the fingers and toes, inside of the thighs and genital organs. Seventy times out of a hundred, scabies is confined to the hands, and in the other thirty, occurs also on the trunk and genitals. The only proof of the existence of itch is the presence of the Acarus, and this is easily to be detected by a microscope adapted for the purpose by M. Bourguig- non. It consists of a body with eye-piece and lenses magnifying seventy diameters linear, with a condensing lens, the whole placed on a movable arm with several joints, attached to a firm stand. With this instrument the entire surface of the body may be explored, and the movements and doings of the insects observed with the utmost facility. The associated papules, vesicles, and pustules are, in the opinion of M. Bourguignon, in no way diagnostic. M. Biett made a series of experiments at the Hopital St. Louis, to determine what substance would cure itch in the shortest space of time. He employed forty-one different applications and modes of treatment. The result was, that frictions with the following ointment occasioned 844 DISEASES OF THE INTEGUMENTARY SYSTEM. recovery on the average in the smallest number of days :—Take of sub- limed sulphur, two parts; of subcarbonate of potash, one part; and of lard, eight parts. M. Albin Grass endeavored to ascertain what substances would most quickly destroy the Acarus just removed from its burrow. It survived three hours in water; two in olive oil; one in a solution of acetate of lead; four-fifths of an hour in warm water ; twenty minutes in vinegar and an alkaline solution; twelve minutes in a solution of sulphuret of potash; nine minutes in turpentine ; and from four to six minutes in a solution of the hydriodate of potash. It survived sixteen hours in the vapor of sulphur under a watch-glass; and one hour in the flowers of sulphur. According to these researches, therefore, hydrio- date of potash would be the best remedy. He removed three living insects from a patient who had taken three sulphur baths, whereas, after a single application of Helmerinch's ointment, that is, where sulphur and potash are combined, he frequently found them dead. M. Bourguignon with his microscope watched with great care the effect of the frictions made at St. Louis with the sulphuro-alkaline ointment. After the first day, in which there had been two frictions and a simple bath, the Acari were in no way disturbed. In two days, after four frictions, they were still active, but burrowed deep in their grooves. In three days they still lived, but were unusually flat; but their eggs could be hatched by artificial heat, and produced larvas, possessing great activity. In four days the insects in the superficial parts were shrivelled up and dead; the deeper ones, though living, tres malades. Many of the eggs now aborted. In five days all the insects were dead; and in six even the eggs had lost their vitality. The eruptions, on the other hand, often remained stationary, and not unfrequently became worse from the irritation of the ointment and frictions, but after a time they disappear also. Hence it is common at St. Louis, after seven or eight days' friction, to send out the patients though still covered with eruption, and in most cases they get well. About three in ten, however, return with the disease again established, a circumstance that Mons. B. attributes to the fact, that the frictions, which were only applied to the superior and inferior extremities, had not destroyed the insects which were present on the trunk. M. Bourguignon, on considering the structure of these Acari, and the facility with which a poisoning fluid could penetrate their delicate integument, was led to make a series of observations to determine how long they would live after the application of various toxic solutions. He found those which possessed the most energetic action on these creatures were solutions of the ioduret of potassium and of the ioduret of sulphur, which killed them in eight minutes. A solution of the alcoholic extract of staphisagria was the next in virulence, destroying the animals in fifteen minutes. The hands of an itch patient were immersed in a solution of the two former for two hours, so as strongly to impregnate and color the integuments. On examining the insects immediately afterwards, they were as lively as ever, but on the next day they were all dead, and the eggs destroyed. JThe epidermis was greatly shrivelled, and in three days complete desquamation occurred, carrying DERMATOZOA. 845 with it Acari, grooves, and eggs, and leaving the cutis raw and tender. The action on the skin was evidently too strong. A bath of a solution of the alcoholic extract of staphisagria was then made, and immediately after a two hours' immersion of the hands, all the insects were found dead, and, with one exception, the eggs destroyed. So far from irritat- ing the integument, this application at once caused the itching to cease, and produced such calmative effects, that M. B. proposes it as a local remedy for inflammation. The eruptions also appeared to be rapidly cured by it. After various experiments, he adopted an ointment of the staphisagria as the most generally useful preparation, prepared as fol- lows :—Recent grains of staphisagria in powder, 300 grammes; boiling lard, 500 grammes. Digest for 24 hours at the temperature of 100° in a sand bath and strain. Four days of friction with this ointment, in- stead of seven with sulphuro-alkaline ointment, not only destroys the insects and their eggs, but completely cures and prevents the integu- mentary irritation and eruptions. Entozoon Folliculorum. This insect inhabits the sebaceous follicles of the skin, and is very common in the face, more especially when the seat of acne. In the Fig 487 Three follicles of the skin of the dog containing entozoa. 100 diam. Fig 488* Cul-de-sac of a sebaceous follicle, containing three animalcules in different positions, and two eggs—(after Gruby). 350 diam. 846 DISEASES OF THE INTEGUMENTARY SYSTEM. and, according to Simon, are almost universal in dead bodies. He frequently found them living six days after the death of the individual in whom they were found. The animal measures from l-135th to l-64th of an inch in length, and from l-155th to l-555th of an inch in breadth. It is composed of a head, a thorax, and abdomen. The head represents in form a truncated cone, flattened from above downwards, and directed obliquely downwards from the anterior part of the trunk. The existence of an eye has not been determined. The head is furnished with two maxillary palpi, which admit of extensive motion. The thorax is the broadest part of the animal, and is composed of four : segments. In each of these, on each side are two legs—eight in all. The abdomen varies in length, is annulated in structure, and admits of certain movements. Inter- nally Dr. Erasmus Wilson has traced out an alimentary canal, and its termination in an anus, together with a brownish mass which he considers to be the liver. No sexual differences have been discovered in them, and they possess no respiratory organs. The animalcule is easily found by com- pressing with two fingers the skin we wish to examine, until the sebaceous matter is squeezed out, in the form of a little worm. This matter should be placed in a drop of oil previously heated, then separated with needles, and examined with a microscope magnifying 250 diameters. Their move- ments are slow, whilst the conformation of their articulations only permits them to move forwards and backwards, like lobsters (Gruby). They are nourished by the seba- ceous secretion of the follicles. They most commonly occupy the excre- tory duct of the follicles, which are often dilated in the places where they are lodged. Their head is always directed towards the base of the gland. When there are many together, they are placed back to back, and their feet are applied against the walls of the duct. When very numerous, they are compressed closely together, and are found deeper in the ducts. They rarely exist, however, at the base of the gland. In young persons they generally vary in number from two to four; in an aged individual, they may be from ten to twenty. (Gruby). Though this entozoon may occasionally be associated with acne, it seldom gives rise to great inconvenience. According to Erasmus Wilson, Fig. 489. Hair and its follicle, in which may be seen the animalcules descending towards the root of the hair, and cul-de-sac of the follicles.—(Gruby.) 100 diam. DERMATOPHYTA. 847 the difficulty seems not to be to find these creatures, but to find any individual, with the exception of newly-born children, in whom they do not exist. DERMATOPHYTA. The growth of parasitic fungi on the surface of the skin has now been observed under a variety of circumstances, and constitutes occasion- ally in man three forms of skin disease—viz., taenia favosa, and certain forms of pityriasis and of metltagra. The latter is very rare in this country; and I have never seen a case of it. All these disorders, however, may be classified under the head of favus, under which I shall consider them. Favus. Case CXCIL*—Favus of the Scalp in an Adult—Incurable. History.—Isabella Fergusson, ast. 22, a somewhat stout servant girl, with fair skin, and scrofulous aspect, was admitted into the clinical ward of the Royal Infir- mary, May 6th, 1849. She states that there has been an eruption on her head for the last twelve years. Four months ago the catamenia ceased, since which time she has been subject to occasional headache, constipation, and slight dyspepsia. Symptoms on Admission.—Nearly the whole of the scalp is covered with a thick yellow friable crust, of uneven surface, and irregular margin, emitting a highly offen- sive odor, like cat's urine, and causing great itching and irritation. Up to the middle of July she was treated with various internal remedies, which subdued the constipation and dyspepsia, and caused return of the catamenia. The crusts on the scalp were removed by poultices, and an ointment composed of ammon. mur. § j ; and ung. sulphuris 1 j, applied locally. Dr. Bennett first took charge of the case on the 14th of June. The head was then again covered with favus crusts, some isolated, others compressed together :and forming an elevated scab. A small portion, examined under the microscope, presented the branches and sporules of the cryptogamic plant so characteristic of the disease. The crusts were again removed by poultices of linseed meal, the head shaved, ana, cod-liver oil ordered to be applied to the scalp morning and evening—the whole to be covered with an oil-silk cap. This treatment was continued for six weeks, but on suspending it the favus crusts returned. During the months of August and September, iodine and pitch ointments were applied: portions of the scalp were even blistered, but without effect. Progress of the Case.—At the commencement of October, the scalp being at the time perfectly clean and closely shaved, all local treatment was suspended, and the reappearance of the disease carefully watched. In three days the entire surface pre- sented a scaly eruption, the epidermis being raised, cracked, and broken up over the whole scalp, which was exceedingly dry and harsh. The furfuraceous condition of the scalp continued, becoming more and more dense, until the fourteenth day, when there were first perceived minute bright sulphur-colored spots in it. These, on being examined microscopically, were seen to be composed of fine molecular matter, mingled with epidermic scales, from which delicate branched tubes were apparently growing. The crusts were now once more removed by repeated poulticing, and cod-liver oil applied as formerly. The scalp continued free from eruption until the 20th of November, when she was seized with febrile symptoms, which ushered in a very severe attack of typhus that ran its usual course. She was not considered fully convalescent until the 8th ot December. During this period, no local application was made to the scalp, with the exception of the cold douche to alleviate the head symptoms, delirium and coma bav- in- been severe. The surface latterly once more became covered with furfuraceous scales ; and on the Uth December the bright yellow minute spots again made their appearance. As her strength improved, the favus crusts increased in size and num- ber, and the progress of this very singular disease was again very carefully watched. Each individual crust, at first the size of a small pin's head, gradually flattened out, * Reported by Mr. William Johnston, Clinical Clerk. 848 DISEASES OF THE INTEGUMENTARY SYSTEM. and became circular. Its centre was cupped and umbilicated, and many, which were more isolated than the rest, grew until they measured a quarter of an inch in diame- ter. More generally, however, they came in contact with others, and groups of twos or threes, and sometimes a dozen, became compressed together and presented the hexagonal form of the honey-comb. Gradually the concavity disappeared. Each crust presented an external dark ring, and an internal lighter centre, which became considerably elevated. The various groups became aggregated together, and she complained of great itching and irritation, and it was evident that, if allowed to proceed further, the condition she presented on admission would be soon produced. The crusts were, therefore, again removed by poultices, cod-liver oil once more applied and the scalp remained clean and free from irritation until 11th January, when the cure appearing to be hopeless she was dismissed. She was enjoined to continue the use of the oil, which, whilst applied, and covered with the oil-silk cap, had the power of preventing the formation of fresh crusts on the scalp. Case CXCIIL*—Favus of the Scalp of three years1 standing—Cured. History.—Margaret Bryer, set. 12, of scrofulous and cachectic appearance, was ad- mitted June 19th, 1849, with favu3 crust on the scalp. The crusts are most numer- ous and dense on the crown of the head ; but others, isolated or in small groups, are scattered over the temples, forehead, and occiput. The scalp is bald here and there in patches, varying in diameter from half an inch to an inch. On examining the crusts microscopically, they are seen to contain the cryptogamic branches and sporules pathognomonic of favus. The disease is of three years' standing, and is attributed to the use of a comb, belonging to another girl who had a sore head. The crusts have been several times removed by means of pitch plasters and a variety of ointments, but have always returned. Progress of the Case.—At first, the crusts were removed and the scalp kept moist by means of an alkaline lotion, which succeeded in removing the irritation. Early in July she was ordered § ss of cod-liver oil three times a day. The oil was also directed to be applied lo the shaved scalp twice daily, which was to be kept constantly covered with an oil-silk cap. This treatment was persevered in until August 10th, when she was dismissed cured. This girl was re-admitted September 5th, and remained in the In- firmary five days, under observation. Up to this time the disease had not re-appeared, so that, when dismissed on the 10th, a permanent cure was undoubtedly produced. Case CXCIV".f—Favus caught in the Ward from Case CXCIL—Cured. History.—Margaret Cameron, set. 5, an ill-nourished, cachectic-looking child— admitted July 23d, 1849, on account of an eruption on the scalp. In some places the hair was matted together by a recent pustular eruption; groups of impetiginous pustules and eczematous vesicles being scattered here and there. In others, where the disease was chronic, hard, nodulated, elevated masses, and friable crusts existed. The disease was eczema impetiginodes. No favus was present, as was proved by careful examination, and microscopic demonstrations of the scabs. Poultices were ordered to the scalp, to remove the crusts ; and afterwards an alkaline wash, with cod- liver oil internally. Progress of the Case.—My colleagues taking charge of the ward during the months of August and September, I lost sight of this patient; but, on resuming duty in the beginning of October, I was surprised to find the child's head covered with favus crusts, with the branches and sporules fully developed, as proved by the microscope. It appeared that the girl was a great favorite with Isabella Fergusson (Case CXCII.), and frequently slept in her bed, and there can be little doubt she had caught favus from her. The child's general health, however, had greatly im- proved ; and the crusts were ordered to be removed by poultices, the head shaved, and cod-liver oil applied locally twice daily, and an oil-silk cap to be worn constantly. This treatment was continued for seven weeks. At the end of that time all treat- ment was suspended, and the scalp watched daily. In fifteen days the head was covered with a slight furfuraceous desquamation ; but the hair was abundant. Another week elapsed without any return of favus; and, her health being now good, she was discharged, December 6th. * Reported by Dr. J. Smith, Clinical Clerk. f Reported by Mr. Alexander Struthers, Clinical Clerk. favus. 849 Case CXC V.*—Favus of the Scalp of four years'* standing, cured by a Sulphurous Acid Lotion. History.—Helen Goodall, aet. 15—admitted November 3d, 1853. She has been affected with favus of the scalp for four years, and frequently been in the Infirmary, and subjected to various kinds of treatment, under different physicians, without any permanent benefit. On admission, a great part of the scalp was bald, from destruc- tion of the hair bulbs, but the other portions were covered with a prominent yellow friable crust, of mousey odor, crowded with pediculi. On the 1th of November a lotion, composed of one part of sulphurous acid and three parts of water, was con- stantly applied by means of lint saturated in it, and covered with an oil-skin cap. It was suspended December 2Zd, leaving the scalp partly bald, but quite clean. On the loth of January 1854, the disease had not returned. The scalp was then rubbed over with the oil of cade, twice daily, to remove the squamous eruption, and she was dismissed apparently quite cured, February 5th. Case CXCVI.f—Limited Favus of the Cheek, cured by Cauterization with Nitrate of Silver. History.—James Scott, aet. 15, a painter, applied for advice, January 27th, 1850. He states that, a week ago, without any known cause, he observed a small spot, about the sjze of a pin's head, over the external angle of the left malan*bone. On examination, a circular reddened spot about the size of a shilling is seen over the ex- ternal angle of the left malar bone, in the centre of which were several favus crusts, aggregated together. These, examined under the microscope, presented the branches and sporules pathognomonic of the disease. The whole was then well cauterized with nitrate of silver, and was cured at once. Commentary.—Of the five cases of favus now given, the first was that of an adult, and was of twelve years' standing. By means of poultices and excluding the air, with oily applications, the scalp could easily be freed from the eruption and kept so; but as soon as these means were discontinued, the disease returned. The second and third cases were permanently cured by the constant application of oil to the scalp for six or seven weeks. They were children of the ages of twelve and five years respectively. In the former the disease was of three years' standing; in the latter, it was altogether recent, and caught from another case in the ward. The fourth case was cured by using a sulphu- rous acid lotion instead of oil—a practice recommended by Dr. Jenner, in consequence of the powerful effect possessed by this acid in destroy- ing vegetable growths. In the fifth case, the disease was limited, and was at once destroyed by means of caustic. It is rare that favus can be watched through its entire progress in the wards of a hospital—first, because the disease commonly lasts months, often years, and charitable institutions cannot support individuals so long,- and, secondly, because it always happens, that when urgent cases demand admission, and beds arc required, these are just the parties who are discharged to make room for them. At the same time, the disease is so common in Edinburgh, that the wards are seldom free of one or more examples of it in various stages. Besides, by poulticing off the crusts, and allowing the eruption to come back, its commencement and progress may be studied in any individual case. * Reported by Mr. P. W. Wallace, Clinical Clerk. f Reported by Mr. Hugh Balfour, Clinical Clerk. 54 850 DISEASES OF THE INTEGUMENTARY SYSTEM. History of Favus as a Vegetable Parasite—(Achorion Schdnleinii of Link.) The demonstration by Bassi* of the vegetable nature of the disease named muscardine in silk worms, which causes so great a mortality amongst those animals, opened up to pathologists a new field for observa- tion, and led to the discovery that certain disorders in the higher animals, and even in man himself, were connected with the growth of parasitic plants of a low type. Sch6nlein,t of Berlin, was the first to detect them in favus crusts—-an observation confirmed by Remak t Fuchs, and Langenbeck.§ Gruby || gave a very perfect description of these vegetations in 1841, and made numerous researches as to their seat, origin, and mode of propagation. These were repeated by myself, and further extended in 1842.11 In 1845 I succeeded in inoculating the disease in the human subject. Since then they have been made the subject of further investigation by Lebert,** Remak,ff Robin,J| and numerous other inquirers, to whose observations I shall have occasion to allude subsequently. Mode of Development and Symptoms of Favus. By most writers, amongst whom may be cited Willan, Bateman, Biett, and Rayer, favus is described as commencing in a pustule, which breaks and forms the peculiar scab. Others, such as Baudelocque, Alibert, and Gibert, deny its pustular nature, and state that it commences in a crust. But numerous observations have satisfied me that the for- mation of pustules is not essential to the disease, although they are often present. Hence the mistake of those pathologists who classified favus amongst the pustulae. M. Gruby says that they are never present, which is equally erroneous, although they appear to be a secondary result, attributable to the irritation the disease produces in some individuals.^ On the other hand, I have never seen this affection produced without having been preceded by desquamation of the cuticle, an observation which appears to me of some importance in explaining the origin of the disease, as we shall subsequently see. Occasionally, also, the scales form a thick mass, and the favus matter is more disseminated, and does not form the distinct umbilicated crusts. This constitutes the parasitic pity- riasis of some writers. After removing the favus crusts by poulticing, and then watching * Del. Mai. del Segno Calcinaccio o Muscardino. Milano, 1837. f Miiller's Archives. 1836. % Medicinishe Zeitung. 1840. § Comptes Rendus de la Polyclinique de Gottingen. || Comptes Rendus, torn. xiii. pp. 72 and 309. 1841. T[ On Parasitic Vegetable Structures found Growing in Living Animals. Edin- burgh Philosophical Transactions, vol. xv. p. 277. 1842. Monthly Journal, June 1842. ** Physiologie Pathologique, torn. ii. 1845. Jf Diagnostiche und Pathogenische Untersuchungen. 1845. \ Des Vegetaux qui croissent sur l'Homme, etc. 1847. §§ This explanation of the origin of pustules and purulent matter, when present, has loeen adopted by Lebert, Remak, and Simon. FAVUS. 851 from day to day how the disease returns, it will be seen that the first morbid change is increased vascularity of the skin, accompanied with a desquamation of the cuticle; and that in a period varying from twelve to fourteen days, small spots of a bright yellow color, like that of sulphur, may be detected. These gradually augment in size, but even at the earliest period may be observed, with a lens, to have a central depression, through which a hair may generally be observed to pass. The crust or capsule may enlarge to about the size of a shilling, and if it be isolated, still retain its rounded form. Usually, however, its edges come in contact with other capsules, and then it loses its rounded shape, and assumes the hexagonal and honey-combed appearances described by authors. I consider, then, that the so-called Porrigo lupinosa, and Porrigo favosa, constituting distinct forms or varieties of some writers, are merely different stages of the same disease, and dependent upon the greater or less aggregation of the crusts. On the first appearance of the capsule, its edges are somewhat depressed below the surface of the cuticle; but as it increases in size, the margins become more and more elevated and prominent, whilst a series of concentric rings or grooves may be ob- served in them. At first, also, the whole capsule appears of a homo- geneous bright yellow, but when further developed, its centre assumes a whiter color. This arises from the aggregation of the sporules of the plant, which are more abundant in this situation. As the development Fig. 490. a, Isolated crusts of Favus, presenting the lupine seed like depression in different stages of growth (so-called Porrigo lupinosa) ■ some are arranged in groups of twos and threes, b, A larger group of these crusts, somewhat compressed at the sides, like a honeycomb (Porrigo favosa), c, Another group, which occurred on the shoulder of a young girl. No hairs passed through the centre of these crusts, d, Large isolated crusts in an advanced state of growth, the external ring is cracked, and the friable centre is enlarged and elevated, e, Numerous crusts aggregated together, so as to form an irregular elevated mass. Traces of the original form may be observed in the cracked rings round the margin. (Natural size.) 852 DISEASES OF THE INTEGUMENTARY SYSTEM. proceeds, this central whitish yellow mass assumes a mealy, powdery con- sistence, and encroaches upon the edges of the capsule, which gradually disappear, whilst its upper concave form becomes convex, as Gruby pointed out. In general, an inflammatory ring is seen round the crust which, as the capsule becomes elevated above the skin, enlarges and assumes a deeper color, indicative of the increased local irritation. At length the whole cracks or splits up; all regular form is lost; a dense thick crust covers the scalp; an odor, like the urine of cats or mice, is evolved; and, in chronic cases, vermin deposit their eggs in the inter- stices, and crawl in large numbers over the surface. I have satisfied myself that occasionally the disease, instead of pre- senting distinct capsules round hair bulbs, becomes diffused under the epidermis, which then assumes the appearance of pityriasis, and not un- frequently of chronic eczema. A microscopic examination, however, will in such cases always detect groups of sporules and thalli more or less developed. In one instance I found the sporules smaller than usual, and perfectly globular instead of oval. In others I have seen the sporules three or four times larger than those of ordinary favus, with in- cluded nuclei, multiplying fissiparously. Hence the so-called parasitic pityriasis of the scalp I believe to be a modification of favus, and con- sider it a good rule, in all chronic eruptions on the head, to examine the erusts microscopically. The other local symptoms are merely those which result from the greater or less degree of irritation produced in different persons by the changes above referred to. At first, scarcely any uneasiness is felt; perhaps occasional slight itching of the part. As the disease pro- gresses, however, the itching becomes more intolerable, and induces the patient to rub and scratch the scalp. By these means, several of the crusts are forcibly torn from their attachments, and considerable effusion of serous fluid and blood is produced. Sometimes inflammation is thus occasioned. Impetiginous pustules are frequently formed, or suppura- tion produced, terminating in ulceration, and the discharge of an ichorous fluid from beneath the crusts. At an advanced stage of the disease, the peculiarly offensive odor exhaled is insupportable to those who surround the individual, and the ichorous discharge, vermin, and crusts, which cover the affected parts, present a most disgusting appear- ance. Although the disease most commonly attacks the hairy scalp, it may occur on the forehead, temples, cheeks, nose, chin, ears, shoulders, arms, abdomen, lumbar region, sacrum, knees, and legs. Alibert gives a plate in which it is figured in all these situations. I have myself seen it on the cheek, shoulders, back, arms, and inferior extremities, and in some of these situations I could detect no hairs perforating the capsules. (Fig. 490, c.) The constitutional symptoms are of the utmost importance, but, generally speaking, receive little attention from practitioners. In most of the individuals affected, who have come under my notice, the general health has been greatly deranged, and a scrofulous or cachectic constitution more or less evident. In some the fades scrofulosa of authors has been well marked ; in others there were engorgements of FAVUS. 853 the lymphatic glands of the neck; and in the only fatal case which has come under my observation, there were found tubercular depositions in the lungs, mesenteric glands, and other textures. Indeed, the gener- ality of individuals who die laboring under favus, perish from phthisis, or other forms of tubercular disease. The beautiful plates published by Alibert are in this respect far from being true to nature ; for whilst the capsules and crusts are accurately drawn, the individuals affected seem to be ideal personages, enjoying the most robust health, and possessing even the utmost beauty of form and feature. In the generality of cases, on the contrary, the patient is thin, the countenance is of a dirty yellow color, and the whole aspect betrays depression of the vital powers. The appetite is often impaired, the alvine evacuations irregular, and the func- tions of digestion and nutrition are impeded. Numerous writers have observed the physical and mental development of the individual to be retarded; and Alibert gives instances where the epoch of puberty was considerably delayed. By those not well accustomed to the diagnosis of skin diseases, favus has often been confounded with other eruptions of the scalp, more especially eczema and impetigo, or the combination of these diseases known as the eczema impetiginodes. In none of these eruptions, how- ever, do the yellow crusts or scales present traces of vegetations when examined microscopically. This, therefore, furnishes the real diagnostic and pathognomonic character of the disease.* Occasionally, as has been stated, favus presents a scaly character. It has then been called Pity- riasis. On examination of the scurf, however, the epidermic scales will be found associated with the Achorion Schonleinii, in various stages of development. Causes. Alibert considered the disease hereditary, and gives eases confirma- tory of this view. As regards age, it is by far most common in children between the ages of three and twelve years. In infancy, and after puberty, it is more rare, although sometimes present; and in a few instances it has been observed in persons advanced in years. In almost all the cases which have come under my notice, the individuals have been exposed to causes which depress the vital powers, and are well- known excitants of tuberculous disease. Close questioning will usually elicit that they are of a scrofulous family; have been exposed for some time to infected or corrupted air; inhabited small rooms, or confined streets, or dwellings situated in unhealthy situations; that the aliment has not been very nutritive, etc. etc. Hence, why the disease is com- mon in workhouses and jails, and most prevalent amongst the poorer classes of the population, and individuals who obtain a precarious existence. * In 1842 I discovered Favus on the face of a common house mouse, in which animal the same cryptogamic vegetations were to be detected as in man. Dr. Carter confirmed this observation in a communication he brought before the Royal Medical Society of this city, during the session 1856-57. Prof. Gluge of Brussels also described and figured the same fact (Bulletins de l'Academie royale de Belgique. 2me serie. Tom. iii., No. 12). 854 DISEASES OF THE INTEGUMENTARY SYSTEM. Almost every writer on the disease considers it to be contagious. Bateman, Guersent, and others, speak of its spreading amongst school- boys, from the employment of the same towels, combs, caps, etc. Gibert has seen it propagated in the wards, of St. Louis from the same cause. It has been observed, he says, two or three times to be com- municated by young people kissing each other, when it has appeared in the chin or neighborhood of the mouth. Mahon even pretends to have contracted favus incrustations on his fingers, from having neglected to wash them after dressing the heads of those affected. Alibert, in his early writings, also thought it to be contagious. In his later works, how- ever, he evidently doubts it, says that much exaggeration has been made use of on this subject, and states that the amour propre of parents usually induces them to ascribe the origin of so disgusting a disease to external communication. He further observes, " Mes eleves ont souvent tente d'inoculer en notre presence, le produit de l'incrustation faveuse, sous plusieurs formes, et en variant les procedes. Le plus souvent il n'est rien resulte, dans d'autres cas est survenue une inflammation passagere, qui s'est bientot evanouie—parfois une suppuration semblable qui pour- rait s'etablir par tout irritant mechanique, ou par l'insertion d'une sub- stance etrangere dans le tegument."* Gruby also, on discovering its vegetable nature, inoculated thirty phanerogamous plants, twenty-four silk-worms, six reptiles, four birds, and eight mammifera, but only pro- duced the disease once, and then in a plant. The human arm was inoculated five times, but, independent of a slight inflammation and sup- puration, no effect was produced. Twenty-two years ago I inoculated myself and others many times with a view of determining whether favus was or was not contagious. But in none of these experiments, performed in various ways, and fre- quently repeated so as to avoid fallacy, could I succeed in causing the .plant to germinate on parts different from those on which it was originally produced ; in other words, I could not communicate the disease to other individuals, or from one part of the same individual to another. At the time I did not consider these experiments (performed in 1841-42) as decisive of the question, although they show that it is with great difficulty inoculation succeeds. Shortly after, Dr. Remak of Berlin communicated the disease to his own arm in the following way: —He fastened portions of the crust upon the unbroken skin, by means of plaster. In fourteen days, a red spot, covered with epidermis, ap- peared, and in a few days more a dry yellow favus scab formed itself upon the spot, which, examined microscopically, presented the mycoder- matous vegetations characteristic of favus.f Mentioning this fact to my polyclinical class, at the Royal Dispensary, in the summer of 1845, one of the gentlemen in attendance volunteered to permit his arm to be ino- culated. A boy, called John Bangh, aet. 8, laboring under the disease, was at the time the subject of lecture, and a portion of the crust, taken directly from this boy's head, was rubbed upon Mr. M.'s arm, so as to produce erythematous redness, and to raise the epidermis. Portions of the crust were then fastened on the part by strips of adhesive plaster. * Traite des Maladies de la Peau, fob, p. 443. f Medicinische Zeitung, August 3, 1842. FAVUS. 855 The results were regularly examined at the meetings of the class every Tuesday and Friday. The friction produced considerable soreness, and, in a few places, superficial suppuration. Three weeks, however, elapsed, and there was no appearance of favus. At this time, there still remained on the arm a superficial open sore about the size of a pea, and Mr. M. suggested that a portion of the crust should be fastened directly on the sore. This was done, and the whole covered by a circular piece of adhe- sive plaster about the size of a crown-piece. In a few days, the skin surrounding the inoculated part appeared red, indurated, and covered with epidermic scales. In ten days, there were first perceived upon it minute bright yellow-colored spots, which, on examination with a lens, were at once recognised to be spots of favus. On examination with the microscope, they were found to be composed of a minute granular matter, in which a few of the cryptogamic jointed tubes could be perceived. In three days more, the yellow spots assumed a distinct cupped shape, per- forated by a hair; and in addition to tubes, numerous sporules could be detected. The arm was shown to Dr. Alison ; and all who witnessed the experiment being satisfied of its success, I advised Mr. M. to destroy each favus spot with nitrate of silver. With a view of making some further observations, however, he retained them for some time. The capsules wer% then squeezed out, and have not since returned. Mr. M. had light hair, blue eyes, a white and very delicate skin. There is every reason to believe that the strips of plaster employed in the first attempt shifted their position, and that the crust was only properly retained by the cir- cular piece of plaster employed in the second experiment. That the disease, therefore, is inoculable, and capable of being com- municated by contagion, there can be no doubt, a result which accords with the observations of most practitioners, and with numerous recorded facts. (Case CXCIV.) It must also be evident that it does not readily spread to healthy persons, and that there must be either a predisposition to its existence, or that the peculiar matter of favus must be kept a long time in contact with the skin previously in a morbid condition. ^ Patholoyy. We have seen, when describing the symptoms and mode of develop- ment of the disease, that it is not essentially pustular, and that the pustules occasionally present are accidental. On the other hand, it has been shown that the peculiar favus-crust is composed of a capsule of epidermic scales, lined by a finely granular mass; that from this mass millions of cryptogamic plants spring up and fructify; and that the pre- sence of these vegetables constitutes the pathognomonic character of the disease. In order to examine the natural position of these vegetables micro- scopically, it is necessary to make a thin section of the capsule com- pletely through, embracing the outer layer of epidermis, amorphous mass, and light friable matter found in the centre. ^ It will then be found, on pressing this slightly between glasses, and examining it with a magni- fying power of 300 diameters, that the cylindrical tubes (thalli) spring from the sides of the capsule, proceed inwards, give off branches dicho- 856 DISEASES OF THE INTEGUMENTARY SYSTEM. tomously, which, when fully developed, contain, at their terminations (mycelia), a greater or smaller number of round or oval globules (spori- dia). These tubes are from the t£q to j^ of a millimetre in thickness, jointed at regular intervals, and often contain molecules, varying from __i__ to joVo- °f a millimetre in diameter. The longitudinal diameter of the sporules is generally from 5}7 to -j-^, and the transverse from _i_ to jit of a millimetre in diameter (Gruby). I have seen some of these, oval and round, twice the size of the others. The long diameter of the former measured -Jj of a millimetre. The mycelia and sporules agglomerated in masses are always more abundant and highly developed in the centre of the crust. The thallia, on the other hand, are most nu- merous near the external layer. There may frequently be seen swellings on the sides of the jointed tubes, which are apparently commencing rami- fications. On examining the hairs which pass through the favus crusts, it will Fig. 493. often be found that they present their healthy structure. At other times, however, they evidently contain long jointed branches, similar Fig. 491. Branches of the Achorion Schoenleinii in an early stage of development growing from a molecular matter, and mingled with epidermic scales, from a very minute favus-crust. Fig. 492. Fragments of the branches more highly developed, with numerous spo- rules and molecular matter, from the centre of an advanced favus-crust. 300 diam. Fig. 493. a, A light hair containing branches of the Achorion Schoenleinii (magni- fied 300 diameters linear). The wood-cutter has made the branches too beaded, b, A darker colored hair, containing branches of the plant. 800 diam. FAVUS. 857 to those in the crust, running in the long axis of the hair, which is exceedingly brittle. I have generally found these abundant in very chronic cases; and on adding water, the fluid may be seen running into these tubes by imbibition, leaving here and there bubbles of air, more or less long. There can be very little doubt that the tubes and sporules, after a time, completely fill up the hair follicle, and from thence enter the hair, causing atrophy of its bulb, and the baldness which follows the disease. The various steps of this process, however, I have been unable to follow, never having had an opportunity of observing favus in the dead scalp, and of making proper sections of the skin. Several writers on favus have treated its vegetable nature as a mere hypothesis. At first it was considered, as by Mr. Erichsen* to be " founded merely upon the outward appearance, sufficiently strong cer- tainly, which the cup-shaped crust of favus offers to lichens, or vegeta- tions of a similar description." Subsequently favus was supposed to consist of a mass of cells; and it was argued by Dr. Carpenterf that the vesicular organization is common to animals as well as plants; and hence " to speak of Porrigo favosa, or any similar disease, as produced by the growth of a vegetable within the animal body, appears to the author a very arbitrary assumption." Mr. Erasmus Wilson, in his work on " Diseases of the Skin " (p. 430), as well as in a special "Treatise on Ringworm," is also opposed to the idea of favus owing its essential characters to a vegetable growth. He considers that the peculiar branches and oval bodies previously described are mere modifications of epidermic cells, which in some cases he is of opinion may be transformed into pus cells—in others, into those observed in favus. The branches of the plant he calls " cellated stems," and the sporules, secondary cells; and argues, that mere resemblance to a vegetable formation is not sufficient to constitute a plant. He says, " The statement of the origin of the vegetable formations by roots implanted in the cortex of the crust is un- founded ; the secondary cells bear no analogy to sporules or seeds; and it is somewhat unreasonable to assign to an organism so simple as a cell the production of seeds, and reproduction thereby, when each cell is en- dowed with a separate life, and separate power of reproduction.''^ Lastly, M. Cazenave,§ although he acknowledges himself to be no histologist, says he has sought for the sporules many times, and believes himself authorised to conclude that their detection is not always so easy as is supposed (p. 225). Finally, he denies that favus is a vegetable parasite, and maintains it to be a peculiar secretion, originating in the sebaceous glands, (p. 236). With the exception of Mr. Wilson, who appears carefully to have examined the favus crust, the opposition to the vegetable nature of this production seems to have originated in very imperfect notions as to its intimate structure on the one hand, and that of certain cryptogamic plants on the other. For if long hollow filaments, with partitions at inter- vals, containing molecules within their cells, springing from an unorga- * Medical Gazette, December 1841, p. 415. f Principles of Physiology, p. 453. t On Ringworm, 1847, p. 23. 8 Traite des Maladies Cuir Chevelu, 1850. 858 DISEASES OF THE INTEGUMENTARY SYSTEM. nized granular mass, and giving off toward their extremities round oval bodies, or sporules, arranged in bead-like rows, be not vegetable, what are they ? The animal tissues present nothing similar, while numerous plants, long known to botanists, present the same identical structure. But not only must they be referred to the vegetable kingdom, but to a considerably elevated position among the cryptogamic plants. The protococcus nivalis and torula cerevisice, universally considered as plants together with the sarcina ventriculi, described by Goodsir, are immeasur- ably beneath them in complexity of structure; and many of the mucores or moulds growing in damp places are, as I have satisfied myself by re- peated examination, much more simple in their organism. Any one who looks over the cryptogamia of Greville will at once detect the strong analogy between the structures found in favus and the penicilium glaucum of Link, the aspergillus penicillatus, acrosporium monilioides, sporotorium minutum, nostoc carideum, and other plants therein figured. Indeed, it seems to me surprising how the vegetable nature of these structures can for a moment be doubted by any one who has personally examined them, especially under powers of from six to eight hundred diameters linear. In considering whether the structure described, and now, by every one acknowledged to exist in the favus crusts, really belong to the vegetable kingdom, we should remember that they are not the only formations of this kind which have been found to grow parasitically in living ani- mals. In my original paper,* I described others growing in phthisical cavities, in the sordes on the gums and teeth of typhus patients; and pointed out that they had been observed in the living tissues of mol- lusca, insects, reptiles, fishes, birds, and mammiferous animals. These observations have subsequently been confirmed by numerous pathologists and naturalists. Lastly, we cannot overlook the opinion of botanists themselves concerning this question. The most eminent mycologists, so far as I am aware, have no doubt of the vegetable nature of favus. Dr. Greville, to whom I exhibited them, was quite satisfied of the fact. Brogniart, according to Gruby, and Messrs. Link and Klotzsch, to whom they were shown by Remak, expressed a similar opinion. Brogniart considers them to belong to the genus Mycoderma of Per soon. J. Miiller places them among the genus Oidium; but both Link and Klotzsch consider that they ought to constitute a distinct genus. The former, in consequence, has given it the generic name of Achorion (from achor, the old term for favus), and added to it the designation of the discoverer Schonlein. The following is his description of the plant:— " Achorion Schcenleini nobis orbiculare, flavum, coriaceum, cuti humanae praesertim capitis insidens ; rhizopodion molle, pellucidum, floccosum jioccis tenuissimis, vix articulatis, ramosissimis, anastomoticis (?) ; t mycelium jioccis crassioribus, subramosis, distincte articulatis, articulis inaequalibus irregulari- bus in sporidia abeuntibus; sporidia rotunda, ovalia vel irreyularia, in uno velpluribus lateribus germinantia." The mode of development from sporules has now been determined with considerable exactitude. Remak made small grooves on the cut surface of afresh apple; placed portions of the ,favus crust in them; * Edin. Philosophical Trans. 1842. f I have never seen any anastomosis. FAVUS. 859 then laid the apple, with the cut surface turned upwards, in moist sand; and covered the whole with a glass bell. Under these circumstances, he found that the sporules developed themselves, and he examined them frequently up to the sixth day, when the surface of the apple became of a brown color, and was covered with a rapid growth of Penicilium glaucum, or other kind of mould, among which the structure peculiar to favus could no longer be traced. These observations, however, showed Fig. 494. Fig. 495. Fig. 49C. that the sporules of the Achorion undergo development in the same man- ner as those in other cryptogamic plants. That is, the membrane which surrounds them throws out one or more prolongations, which are con- verted into tubes; and these, in turn, present, generally towards their extremities, a number of sporules, which at length are pushed out, or are disintegrated, and so become free. Figs. 494 and 495 represent the changes observed in the sporules germinating on the surface of the ap- ple; and Fig. 496 shows the thalli, mycelia, and sporules seen in the crusts, produced by inoculation, on Remak's arm. The method of reproduction and formation of sporules may be ob- served with great facility in any well-developed favus crust, especially under powers varying from 500 to 800 diameters linear. Thalli, with variable-sized cells, may be observed branching at the extremities, with sporules forming within them. These are conjoined with separated my- celia, containing well-developed sporules, many of "which are also free, as in Fig. 497. It follows, therefore, that all the circumstances connected with the development and mode of reproduction of the Achorion Schoenleini have been fully ascertained. The seat of favus has been much disputed by authors. By some it has been located in the piliferous bulbs or follicles (Duncan, Baudelocque, Rayer), by others in the sebaceous glands (Sauvages, Underwood, Mur- ray, Mahon, and lately by Cazenave), and a third party in the reticular tissue of the skin (Bateman. Gallot, Thomson). According to Gruby the plants grow in the cells of the epidermis, the true skin is compressed, Fig. 494. Sporules developing on the surface of an apple, after three days. Fig. 495. The same after four days. Fio-. 496. The same more fully developed on the human arm, after inoculation, a, Thallifwith'pale walls ; b, containing sporules (mycelia); c, mycelium separated from the thallus : d, sporules separated from the mycelium—(after Remak). ' 300 diam. 860 DISEASES OF THE INTEGUMENTARY SYSTEM. not destroyed, and the bulbs and roots of the hairs and sebaceous fol. licles are only secondarily affected. I have made observations to determine the correctness of this state- ment, and have found that the whole inferior surface of the capsule is formed of epidermic scales, thickly matted together. These are lined by finely molecular matter, from which the plants appear to spring, and which unites the branches and sporules together in a mass. Superiorly Fig. 497. however, the epidermic scales are not so dense; and I have always found them more or less broken up, and not continuous. This observation is valuable, as indicating the probable mode in which these plants, or the sporules producing them, are deposited on the scalp. It will be seen that the appearance of the peculiar porrigo capsule was invariably pre- ceded by a desquamation of the cuticle, that is, a separation or splitting up of the numerous external epidermic scales which constitute its outer- most layer. Hence it is more probable that the sporules, or matters from which the vegetations are developed, insinuate themselves between the crevices, and under the portion of epidermis thus partially separated, than that they spring up originally below, or in the thickness of the cuticle. The chemical constitution of the matter originally exuded is supposed by M. Cazenave to be allied to fat, but it appears to me to be more pro- bably albuminous, and allied to the molecular character of all broken down or disintegrated organic material in which fungi grow. We have seen that, previous to the return of the favus crusts, the head is al- ways covered with broken-up epidermis, more or less disintegrated. Ex- periments have shown that the plants will not grow on the healthy skin, and that inoculation succeeds only in places where pustules have pre- viously been formed. It is also exceedingly probable that, when favus is communicated from one person to another, the part affected (generally Fig. 497. Thalli, mycelia, and sporidia of the Achorion Schoenleinii showing the mode of reproduction. 800 diam. FAVUS. 861 the scalp) has been the seat of some other eruption (Case CXCIV.) or is not particularly clean. Mr.. Erichsen considers, " That the matter of favus is a modification of tubercle—that it is a tubercular disease of the skin. By tubercular I do not mean a disease like lupus, characterised by small firm tumors, but a disease, the nature of which consists in the deposition of that heretologous formation called tubercle." This view of the nature of favus I have long held; and it was distinctly stated by me, when treating of the pathology of scrofula, in a work published in 1841.* The favus crust, however, is not constituted wholly of the tubercular matter. The peculiar exudation only constitutes the soil from which the mycodermatous vegetations spring, as I shall now endeavor to show. Gruby describes the mycodermata of favus as springing from an amorphous mass, of which the periphery of the capsule is composed. This mass undoubtedly exists, and, according to my observations, is com- posed of a finely molecular matter, identical in structure with certain forms of tubercle, or recently coagulated exudation. The cheesy matter, for instance, so frequently found on the secreting surface of serous mem- branes, and in tubercular cavities and other structures in chronic cases of tuberculosis, or general tendency to tubercular deposition, presents this character. Every pathologist who has minutely examined tubercle recognises a granular form in which there is no trace of nucleus or cell, and which, therefore, we are warranted in considering as unorganised. I have myself repeatedly examined this tubercular matter, and been unable to detect any difference between it and the mass in which the vegetations of favus appear to grow. Chemical analysis of this form of tubercle demonstrates it to be composed principally of albumen, with^ a minute proportion of earthy salts; sometimes there is combined with it a small quantity of fibrin or gelatine. If this general result be compared with the analysis, by Thenard, of favus matter, the identity between it and tubercle must appear highly probable. He found in 100 parts, coagu- lated albumen, 70 ; gelatine, 17 ; phosphate of lime, 5 ; water and loss, 8 parts. Thus the evidence furnished by morphology and chemistry agrees in determining the molecular matter found in the crusts of favus and in tubercle to be analogous. Remak found that, although the sporules underwent developmental changes on the cut surface of an apple, as well as in animal fluids to which su^ar had been added, no such changes took place m spring or distilled water, in the serum of blood, solution of albumen pus, muscle, substance of brain," cut pieces of skin, or animal fat. In these cases the animal tissues, as well as the portions of favus crust became gradually disintegrated, and infusorial formations commenced. Hence the Achorion grows under the same circumstances only as all other moulds. Putrefac- tion of animal or vegetable substances is unfavorable to its production; but that peculiar acid change which occurs in milk or paste exposed to the air for some days, and in which growths of mould and confervae readily occur, is beneficial to the development of favus. Hence why inoculation in healthy tissues fails, and why certain exudations m peculiar states of the constitution, or disintegrated matters which have * Treatise on the Oleum Jecoris Asselli, p. 94. 862 DISEASES OF THE INTEGUMENTARY SYSTEM. undergone particular chemical changes, probably from acid secretions of the skin, are necessary to the production of the disease. I believe, therefore, that the pathology of favus is best understood by considering it essentially to be a form of abnormal nutrition with exudation of a matter analogous to, if not identical with, that of tubercle which constitutes a soil for the germination of cryptogamic plants the presence of which is pathognomonic of the disease. Hence is explained the frequency of its occurrence in scrofulous persons and among cachectic or ill-fed children; the impossibility of inoculating the disease in healthy tissues, or the necessity for there being scaly, pustular, or vesicular eruptions on the integuments, previous to con- tagion. But as experiments have proved the possibility of inoculation in healthy persons, it follows that the material in which the vegetations grow, may at the commencement, in a molecular exudation, be formed primarily or secondarily. That is, there may be want of vital power from the first, as occurs in scrofulous cases, or there may have been production of cell forms, such as those of pus or epidermis, which, when disintegrated and reduced to a like molecular and granular material secondarily, constitute the necessary ground from which the parasite derives its nourishment, and in which it grows. Treatment. Almost every species of treatment has been had recourse to, in order to remove this disagreeable and intractable disease; and there can be no doubt that cases have recovered under the use of all and each of the methods recommended. In some instances, favus wears itself out, or rather, as the development of the frame proceeds, and the constitutional strength improves, the - conditions necessary for its production and maintenance are removed, and it consequently disappears. In every case, however, it must be our object to get rid of the disease permanently as soon as possible, and this is only to be done by removing the pathological conditions on which it depends. The notion that it originates in' the bulbs of the hair caused an attempt to remove the disease by eradicating the structures with which it was supposed to be connected. Hence the barbarous and cruel treat- ment by means of the Calotte. * This consisted in spreading a very adhesive plaster inside a cap, which closely fitted the shaven scalp. The hair was then allowed to grow and insinuate itself amongst the substance of the plaster—when the whole was forcibly torn off. In this way portions of the scalp were sometimes separated—at others, pieces of the plaster remained firmly attached, and gave great trouble. A modification of this plan consisted in covering the head with the plaster in strips, which were removed separately from before backwards, and from behind forwards, so as to tear out the hairs. Even this plan failed. The practice I saw adopted in Berlin, in 1841, consisted in plucking out the hairs individually with a pair of pincers; but this tedious and painful method, also, was found to be of little service. It has been revived of late years by Bazin and Hardy in Paris, and has also been practised in Glasgow by Drs. Anderson and Buchanan, at the skin Dispensary there. According to the former, so called paracitides require to be used after FAVUS. 863 deputation, to destroy the fungus, removal of the hair bulbs being a means for enabling the medicine to reach the germs. The success of this practice has yet to be established. In Paris the old treatment by the calotte was put aside for the milder empiric treatment of the freres Mahon. Between the years 1807 and 1813, 439 girls and 469 boys, affected with favus, were cured by them at the Bureau Central des Hopitaux, and the mean duration of the treatment was 56 applications. These applications are generally made every other day, so that the average length of treatment by this much boasted and successful method is three months and a half. I have endeavored to show, however, that in many cases it is a constitutional disease, and dependent upon the causes which induce scrofulous diseases in general. The treatment, therefore, in such ought to be constitutional, and directed to removing the tendency to tubercular exudation, on which the malady depends. No doubt, however, a local treatment in this, as in all disorders which are at the same time general and local, is of the utmost service. I consider, then, that the chief indications of treatment are—1st, To remove the constitutional derangement; ajad, 2dly, To employ such topical applications as tend to prevent the development of vegetable life. This line of practice may be thought similar to that recommended long ago by Lorry, who advises, 1st, A modification of the fluids and solids of the economy by a general treatment; 2dly, A vigorous attack upon the local disease by topical applications, capable of removing the crusts, causing the skin to suppurate deeply, and substituting a solid cicatrix for the morbid ulceration of the hairy scalp. For the most part, however, the general treatment of physicians has been confined to diluent drinks, blood-letting, purging, and remedies which depress the vital powers, whereas it must be evident, that if the views of its patho- logy I have brought forward be correct, and it is in its nature allied to tubercular affections, a treatment exactly opposite ought to be pursued. The development of vegetable life may also be prevented by the applica- tion of much milder remedies than the escharotics or irritating ointments usually employed. We have previously seen that tuberculosis is caused and kept up by some fault in the digestive process; that the blood is secondarily affected, and its albuminous constituents proportionally increased; that t opaque and dull, in no way resembling the \ 1 |j*3j ffi sin gelatinous appearance of a healthy decolorised clot. When squeezed out of the veins, as was sometimes accidentally done where they were divided, it resem- bled thick creamy pus. In some portions of the Fig. 502. veins, the clot was wholly formed of red coagulum. In others it was divided into red and yellow. In a few places the yellow formed only Fig. 501. Fi". 501. Portion of clot from the vena cava, showing the divisions into red and white coagula. Half the real size. ..... Fie. 502. Posterior surface of the aorta and vena cava. An incision has been made Tn the latter, to show that it is not thickened or diseased, as well as to expose colorless coa\ Respiratory and urinary systems f® q\ %£& q £T\ healthy. The appearance of (he J/ f^\ " *§_/ blood drawn from the extremity !T(5)) ^ ^Sft-\ --. g, of the finger, when magnified 250 xy/^l li^'fey * diameters linear, is represented } f£\ ^/^Sf^ ft ~" $&) ^S- 509- '^he colored corpuscles L)nlfi&»P§ F ^ #> CL? ^for the most part have collected fcT) plumbi opiat. unam ter in die, et Syrupi Iodidi Ferri guttas /ft'•. **$S quindecim ter in die ex aqud. lllinatur Tinct. Iodinei parti \ftft —, /£~^\ dolenli. lntermitantur alia. March 24th.—During the /""ft, " (e®) "&*%) last few weeks the hemorrhage from the nose and gums has ^ftft-.v ft^',.. *"" continued to recur, and the ascites has not abated. He was ,.-,. (£*ftfe f&) /"ft ordered an astringent lotion for his gums. Since the 11th, i £) "^ ''---ft ftft \@J Spongio-piline, with Tr. of Digitalis, has been applied to the <"'-' rT\, ('©0 j ^^, abdomen, which apparently, in consequence, is less tense, /'~*w *ftap-"'rS;. while the pain has undoubtedly diminished. April 8th.— I5ft! //ft- i ) Diarrhoea again violent. Stools very fluid. He suffers also ..... ^f?- '"'"' from cough, and there is harshness of respiratory murmurs, Fig. 511. and prolonged expiration to be heard at the apices of both lungs. No dulness on per- cussion. Sumat pil. plumbi opiat. unam ter in die. April 13th.—Pain in abdomen, aud diarrhoea nearly gone. Sweats profusely at night. R Quina; Sulph. gr. xij; Acidi Sulph. dil. 3j; Syrup. Aurant. 3J; Aqua; font. § v. M. Ft. Mistura; sumat 3 ss ter in die. Repetantur pil. plumbi opiat. April 23d.—The diarrhoea has ceased for the last eight days, but to-day has returned with considerable pain. Intermittatur mist. Quina; Sulph.; Applicetur emplastrum Opii (4 x 4) abdomini; Sumat pil. plumb, opiat. ij ter in die ; Utatur enem. amyli cum Sol. Morph. statim, et suppositorio opii quotidie hord somni. May 5th.—Has complained a good deal lately of nausea and vomiting, for which he has been ordered a draught every evening, with naphtha. He has also taken the squill and digitalis pill three times a-day, and the tumor has been fomented with infusion of digitalis. Girth of abdomen at this period was thirty- seven inches. R Sp. A^th. Nitrici § iss; Aquce Potasses ; Sol. Mur. Morph. aa 3 ii; M. Sig. sumat 3 j ex aqua ter in die. May 1th.—Distention of abdomen from accu- mulation stil increases, and pain continues. The urine presents an acid reaction, and is loaded with a copious sediment of lithate of ammonia, with a few colorless rhom- boidal crystals of lithic acid. R Pulv. Scillce 3j ; Pulv. Digitalis gr." x; Extr. Hyoscy. 3 ss ; Cons. Rosarum q. s., ut fiant pilulce xx; Sig. sumat unam ter in die. May 13th.—Since last report diarrhoea has been very profuse, the bowels having been acted upon sometimes twenty times in the course of a night. Stools very loose but faeculent. Spongio-piline with digitalis to be discontinued, on account of its pressure causing uneasiness. He has taken the lead and opium pills four times a day, as well as the starch injection, with Sol. Mur. Morph. at night. Omittantur pil. plumbi opiat. R Tannini gr. xv; Pulv. Opii gr. vj ; Cons. Rosarum q. s. ut fiant pil. vj ; sumat unam sextd qudque hord. R Acidi Nitrici dil.; Syrupi aa 3ss; Aqua: %j. M. et Sig. sumat 3 j ter in die ex aqud. June 1st.—Since last report the diarrhoea has con- tinued, but it is now much abated. Fluctuation in abdomen evidently diminished. There has been occasional slight epistaxis. Still sweats at night. Girth of abdomen at broadest part diminished to thirty-five and a half inches. Intermitt. mist. Quince. June 12th.—Has progressed favorably to this date; the tumor and ascites continue to diminish; and the diarrhoea and other symptoms having abated, the abdomen is now flaccid, and the skin is cracked, similar to what is observed in a woman after preg- nancy. To-day the diarrhoea has returned with some violence, with abdominal pain. Habeat Pil. Tannini ut aidea. June 26th.—Diarrhoea still more diminished. There is a good deal of cough, with some expectoration, and harsh respiration is heard under clavicle with increased vocal resonance. Has been taking 3 ij of cod-liver oil three times a'day. His general strength is now greatly improved. He sits up the greater part of the day, and even walks about on the green. His amendment is so Fft 511. The same after the blood has stood for twenty-four hours. 250 diam. 876 DISEASES OF THE BLOOD. great that he is very anxious to return to his parents, who reside in Hull. August Uth.__Since last report the diarrhoea has returned at intervals, and still continues to be troublesome. On the whole, however, his health has improved; his appetite and strength have increased, and all ascites nearly disappeared. The cough and expec- toration have ceased. The tumor measures transversely thirteen and a half inches, and longitudinally fifteen inches. From the lower border of ribs to inferior margin of tumor ten inches. The circumference of the abdomen at the widest part (a little above the umbilicus), is thirty-four inches. He was now dismissed, having for some time expressed great impatience to return to his friends in Hull, and the further pro- gress of the case has been kindly communicated to me by Dr. Sandwith of that town. For some time he was in the Infirmary there, when the same symptoms were observed, more or less severe, that had been previously noticed. Then he lived at his parents' hovel, and finally he went into the Union Work-House, where he died at midnight, July 22, 1851. During all this time the abdominal swelling from the tumor continued, but he had no ascites; the diarrhoea was more or less urgent; the emaciation extreme, and the weakness gradually progressive up to the moment of dissolution. Sectio Cadaveris.—Twelve hours after death. This was performed by Mr. West, surgeon to the Union Work-House. The follow- ing report of the appearances observed was communicated to me by Dr. Sandwith :— Extreme attenuation of the entire body. Thorax.—The heart was small, very small, with a few patchy points on its sur- face. Its cavities contained a whitish imperfectly-formed lymph. The lungs had so per- fectly healthy an appearance that we did not think it necessary to cut into them. There was no more effusion into either the pleural or peritoneal cavities than is quite natural. There was, however, an effusion, a little in excess, into the bag of the pericardium. Abdomen.—Nothing unusual in the appearance of structure of the liver, save that the larger hepatic vessels were filled with small patches of coagulated black blood, side by side with immense flakes of dirty white matter, like imperfectly formed lymph. The gall-bladder was filled with a glairy amber-colored fluid, not much like bile. The liver weighed three pounds twelve ounces. On cutting into the organ there oozed out from the smaller vessels a very thin watery blood. The spleen weighed three pounds four- teen ounces. Its surface was of a sky-blue color, and dappled with numerous specks like cicatrices, most of them very small, but there were two much larger ones near the summit. It adhered here and there by bands of lymph to the peritoneal lining of the abdomen, and also to the peritoneal covering of the intestines. On the under surface of the organ there was a very small globular lobule, enveloped in organised lymph. A cord, run lengthwise along both surfaces of the spleen, measured twenty-four and a half inches. A cord similarly applied across the organ, measured eighteen inches. The structure of the spleen was very firm—indeed very much like that of fiver. The omentum was entirely wasted. The mesenteric glands were most of them somewhat enlarged, pale, and with hard gritty matter in some of them. There were several en- larged glands at the caput caecum in a state of congestion. Pale enlarged glands were also seen all along the sigmoid flexure of the colon. The kidneys were unusually shrunken and small, and weighed together six ounces. There was but little difference in the relative weight of each. Their structure was firm. Microscopic Examination.—Next day I received from Dr. Sandwith a portion ot the spleen, about four inches long, three inches deep, and one inch thick; with a no- dule, the size of a large bullet, at the hilus of the organ. In structure, it was found to be simply hypertrophied, the fusiform cells of the trabeculae presenting their normal charac- ter and arrangement, and the cells of the pulp unusually abundant. I also received por. tions of the clot taken from the heart, vena cava ascendens, and vena portse. They presented exactly the same appearance as the clot in case CXCIX., divided into a dead- white purulent-looking layer, and a tolerably strong healthy-looking red one. Ihe former, on microscopic examination, was almost wholly composed of colorless corpuscles, aggregated together by molecular fibres of fibrin; and the latter, though principally composed of colored corpuscles, also contained many colorless ones. Two of the en- larged mesenteric glands which were sent, on section yielded a copious juice, that con- tained the same cells as are represented Fig. 50. Commentary.—This boy was in the Infirmary upwards of six months, and the symptoms and entire progress of the case were watched with the greatest care. Unlike the former case the spleen was the only organ LEUCOCYTHEMIA. 877 enlarged, the liver presenting its normal dulness on percussion. The abdomen, however, was also the seat of ascitic distention. The smallest drop of blood taken from the boy's finger exhibited, during the whole of his residence in the Infirmary, the excess of colorless corpuscles, and ■ the number of these underwent no perceptible increase or diminution, notwithstanding the varieties of treatment to which he was subjected. Owing to the theories which have been from time to time advanced re- garding the functions of the two kinds of corpuscles found in the blood, and of the nature of its coloring matter, iron was the drug wnich seemed indicated. This boy had also lived in the fenny districts of Lincolnshire; and, although he denied ever having been affected with intermittent fever, it seemed very probable that the enlargement of the spleen was owing to this cause. I commenced the treatment, therefore, with the exhibition of iron and quinine. Other symptoms, however, became so urgent as to demand special attention, and the suspension of these remedies. I allude to the diarrhoea and dyspnoea, the former of which constituted the leading symptom of the disorder during the entire period he remained in the house. All kinds of astringents were given, with occasional temporary, but never with permanent advantage. At one period he was so exhausted that for some weeks I daily expected his death. He, however, again gained strength; and his bodily powers, except towards the termination of his residence in the house, were sub- ject to considerable variations, evidently dependent on the amount of diarrhoea. In April, pulmonary symptoms were added to his other complaints; and from the character these presented, as well as from the physical signs, a strong suspicion was formed that he labored under phthisis pulmonalis. Under a tonic treatment, with cod-liver oil, assisted by the advance of summer, these symptoms diminished, and his general strength was so improved that, as is stated in the report, he insisted on going home. At the time of his discharge he was remarkably ill, greatly emaciated, cachectic-looking, with an enormous abdomen,—so that it was only by comparison with what he had been that he could be said to enjoy tolerable strength. It seems, however, that he reached Hull, by the steam-vessel, in safety, and lived nearly a twelvemonth longer, so that altogether he was under medical observation nearly eighteen months, the morbid condition of the blood existing during the whole of that time. After death the appearance and structure of the coagulated blood exactly resembled that presented in the former case, and there was the same hypertrophy of the spleen and similar enlargement of the lymphatic glands, but not to so great an extent. The liyer, however, was normal, and the lungs externally healthy, but not cut into. Dr. Robertson was kind enough to analyse the blood for me in this case, and from the results he obtained, it appears that the fibrin was in- creased to about double its amount in healthy blood. The albumen and salts existed in their normal proportion. The globules were diminished to about one-half their proper amount, which deficiency was counter- balanced by an increase in the amount of water. ^ This combination of increase in the amount of fibrin and diminution in the amount of cor- puscles, indicates a condition of the blood which, so far as I am aware, is not peculiar to any other morbid condition of the economy. 878 DISEASES OF THE BLOOD. Case CCL*—Commencing Leucocythemia determined during Life— Enlarged Spleen and Liver—Ascites. History.—Thomas Welsh, a sailor, aet. 20—admitted into the clinical ward of the Royal Infirmary, September 22d, 1851. In June 1847, he first experienced a gnawing pain in the left side, and a hard swelling was distinctly felt in the splenic region. Shortly afterwards he was attacked with jaundice, and he became sensible of a swell- ing also on the right side of the abdomen. He says that, owing to medical treatment this latter swelling disappeared, and he regained his health. Since then he has occa- sionally had attacks of jaundice, and the abdomen has slowly enlarged, notwithstand- ing the internal use of large quantities of mercury and iodine. Symptoms on Admission.—On admission, his body generally is emaciated; the abdomen is considerably enlarged, measuring thirty-two inches round the most promi- nent part, which is two inches above the umbilicus ; no fluid can be detected. The hepatic dulness measures vertically at its deepest part six inches, and its lower margin can be distinctly felt below the ribs, the left lobe sweeping backwards and upwards, and apparently coming in contact with the spleen. The splenic dulness measures verti- cally eight and a quarter inches; the anterior margin can be distinctly felt, with a notch in its centre, terminating on a level with the upper edge of the iliac bone. Bowels are generally loose; respiration is embarrassed and thoracic; no dulness on percussion over the chest; no cough, but occasional sibilation heard on auscultation; impulse of heart feeble, otherwise normal; pulse 78, small and weak. He has not in- creased in stature since he was sixteen, and has the external aspect of a boy of that age; generative organs not developed ; urine healthy; skin of a dingy yellowish color. On microscopic examination of the blood, it was ascertained that the colorless and colored corpuscles presented their normal relative number. It is unnecessary to follow the progress of this case minutely. It will suffice to say that the bowels every now and then became very loose; he occasionally had epistexis, and frequently more or less tenderness over various parts of the swollen ab- domen. In October he experienced a severe attack of acute laryngitis, from which he recovered in fifteen days. During the latter part of December ascites came on, the excretion of urine diminished in amount, and it was intensely loaded with lithates. The blood had been examined from time to time, and on the third of January a de- cided increase of the colorless corpuscles was observed. A diuretic treatment, by in- creasing the amount of urine, caused the ascites to diminish. But the number of colorless corpuscles gradually increased, so that, during the whole of February, con- siderable groups of these bodies could be seen between the rolls of colored discs in a demonstration under the microscope. Latterly, his general strength became much diminished; but his mother insisted on taking him home to Berwick, and he left the Infirmary, February 27, 1852. I learnt from Dr. Johnson that he died two days after reaching Berwick. There was no post-mortem examination. As soon as it was determined that the colorless corpuscles of the blood had de- cidedly increased, I requested Dr. W, Robertson to analyse the blood, which he did on the 7th of January, with the following results:—The blood coagulated firmly, but little serum exuded from the coagulum, although it stood undisturbed for forty-eight hours. Surface of coagulum flat, and thinly coated with fibrin. Density of blood.....................................1043 • 5 " of serum....................................1027' Composition of 1000 parts. Fibrin............................................. 3 • 2 Serous solids, \ ?rSanic. J°'J r.................... 80"7 ' (Inorganic, 10 • 3 f Globules........................................... 82-3 Total solids____...................... 166-2 Water............................... 833-8 1000 Commentary.—Up to the occurrence of the present case, no example of leucocythemia had been met with in which the disease was seen to * Reported by Mr. Wm. M. Calder, Clinical Clerk. LEUCOCYTHEMIA. 879 commence and progress. It will be observed that the spleen and liver had attained a very large size before the blood became affected. Nothing, indeed, can be more various than the mere bulk of one or more of the blood glands, and the leucocythemic condition of the blood. In several cases the spleen has been greatly hypertrophied, without any change in the blood whatever. The true explanation of these apparent discrepancies has yet to be discovered. The increase of colorless cells must commence at some particular time, but the exact period of com- mencement has been observed subsequently only in one other case by Virchow. Case CCIL*—Eczema of the Trunk and Limbs—Enlarged Lymphatic Glands—Leucocythemia, which sensibly diminished. History.—Peter Smellie, aet. 62, workman at an iron foundry near Glasgow— admitted October 4th, 1860. Sixteen years ago his legs and ankles first became covered with an eczematous eruption, which disappeared in three or four weeks, but generally returned every spring. Four years ago the shoulders were affected, and from that time it has gradually extended in patches over the trunk and extremities. For the last three years the glands in the groin and the axillae have become enlarged, and three abscesses have been opened in the right groin, the formation of which were preceded by febrile symptoms. Symptoms on Admission.—The entire trunk is covered with chronic eczema, of a dusky red, and, in some places, brown color. The skin, here and there, is indurated, and from the entire surface copious laminated scales are peeling off, accompanied by great irritation and itching. All four extremities are similarly affected; but on the legs the integument is dense and hard, and the scales so thick as somewhat to resemble ichthyosis. The axillary and inguinal glands are greatly enlarged, consisting of bunches of tumors, soft to the feel, and varying in size from a hazel nut to that of a small hen's egg. Other enlarged glands may be felt behind the sterno-mastoid muscles, and at the flexure of the elbows. Another gland, size of a pigeon's egg, exists on the left side of the thorax, inside the nipple. A soft systolic murmur is audible at the base of the heart. Pulse 69, somewhat weak. Dulness over liver and spleen normal. The blood contains a great increase of colorless corpuscles, with numerous naked nuclei, exactly similar in size and appearance to those represented Fig. 522. The diseased skin over thighs and trunk was ordered to be kept moist with a light alkaline lotion (see Skin Diseases, p. 837), and the legs to be anointed with Ung. Zinci. Steak diet. Progress op the Case.—December 28th.—Since admission the eczematous surface has been treated by the alkaline lotion and Ung. Zinci, and is now everywhere much better, in some places well, and entirely free from itching and irritation. The glands in the axilla and groin are diminished in size. January 15th.—Dr. Murray Thomson was kind enough to analyse the blood for me, with the following results :— Composition of 1000 parts of blood. Fibrin.............................................. 3-83 *—-^iS3S5**?Sf ..................:m' Globules............................................ 79-33 Total Solids................171-03 Water....................828-97 1000-00 January 30th.—The skin eruption is now gone from the trunk, but the legs remain indurated and of a mahogany color. The glands are much reduced in size, and the colorless corpuscles in the blood are not so numerous. Dismissed. Commentary.—This man, in his occupation at an iron foundry, was * Reported by Messrs. D. Murray and J. S-idler, Clinical Works. 880 DISEASES OF THE BLOOD. constantly exposed to the heat of large fires, which at leugth excited eczematous inflammation of the skin. This in its turn caused irritation and enlargement of the lymphatic glands, and, as a consequence, leuco- cythemia. The colorless corpuscles in the blood presented exactly the same size and appearance as I previously noticed in a case of cancerous enlargement of the thyroid and lymphatic glands (Case CLXIIL), and could leave us in no doubt as to the source of their origin. (Figs. 522 and 523.) It was interesting to observe that, as the skin eruption and irritation diminished, the glandular enlargements and the leucocythemia diminished also. The four previous cases, together with eight others previously re- corded in this work (Cases LXXIII., LXXVIII., LXXXV., XCIV., CXXV., CLXIIL, CLXXXIX, and CXC), are sufficient for the study of this important lesion of the blood. In my work on Leucocythemia, published in 1852, I have given thirty-seven cases more or less illustra- tive of the symptoms and pathology of the disease. Since then I have myself met with a considerable number of others, and many more have been published in the British, American, French, and German periodi- cals. Several other analyses of the blood also have been made. But very little advance seems to have occurred in our knowledge of the pathology and treatment of leucocythemia since I wrote in 1852, whilst all the facts which have been published confirm the conclusions which I then arrived at. A systematic account of the symptoms and progress of the disease, divided, as is usual among French writers, into three stages, has been compiled by M. Vidal,* chiefly from the facts contained in my work. It has been carefully done, although the basis as regards /lum- ber of cases (only 32) is not sufficiently large. Patholoyy and Treatment of Leucocyhtemia. If the blood of living persons affected with this disease be examined microscopically (which is most readily accomplished by extracting a drop from the finger by pricking it with a needle and placing it between glasses, under a power of 250 diameters linear), the colored and color- less corpuscles will be at first seen rolling confusedly together, and the excess in number of the latter at once perceived. This, however, be- comes more evident after a short time, when the colored bodies are ag- gregated together in rolls, leaving clear spaces between them, which are more or less crowded with the colorless ones. Means are altogether wanting to enable us to determine with exactitude the relative propor- tion of the two kinds of corpuscles in different cases. In some the colorless corpuscles are only slightly increased beyond their usual num- ber. In one case they are described as five times as numerous as those in health. They are also said in particular instances to be " greatly in- creased," " one-third as numerous," and " as numerous," as the colored corpuscles. In all these statements there is nothing exact. Perhaps the best method of judging is to regard the spaces or meshes left be- tween the rolls or aggregations of yellow blood corpuscles. When these are completely filled up, the colorless bodies do not, in fact, amount to one-third of the colored ones, on account of the large number of the lat- * Gazette Hebdomadaire, 4 Avril 1856. LEUCOCYTHEMIA. 881 ter which may exist in a small space, in the form of rouleaux. This will appear upon counting them in Fig. 509, p. 874. The size of the colorless corpuscles in the various cases given, differs considerably. Even when at first sight they appear to be of tolerably uniform size in any one case, it may be observed, when they are magni- fied highly and carefully measured, that some are twice the size of others, with all the intervening sizes between them. In some cases, though comparatively few in number, they are described as rf^ ^ ©^i2§&^ ^^ (j^) being three or four times larger than the colored corpuscles, g\ idjfii&dflmfllilP^ ft^\^ and in three cases they were ftSsSraT^TSy® ^ in one about the same size, or somewhat smaller, Fig. 514, Fig. 512. Fig. 518. and in two others of two sizes, one larger and the other decidedly small- er, Figs. 522, 523. » In the cases in which the blood was carefully examined after death, the same variations with regard to number and size of the colorless cor- puscles were found to exist, as have just been referred to in blood drawn fresh from the finger. It was always observable, however, that they were most numerous in the clot; and when they existed in any number, as in case CXCIX., they communicated to the colorless coagulum a peculiar dull, whitish look, and rendered it more friable under pressure. When less numerous, portions of the colorless coagulum from the heart and large vessels might be seen to present a dull cream color, easily dis- tinguishable from the gelatinous and fibrous appearance of a healthy clot, and such altered portions always contained a large number of the color- less bodies. The blood has been carefully examined chemically in several cases, from which it would appear that there is generally an excess of the fibrin and diminution of the corpuscles. The former ranges from 3 to 7 parts, and the latter from 100 to 49 parts in a thousand. In a well-recorded case by Dr. Wallace of Greenock, the blood was analysed by Dr. W. Robertson, and ascertained to contain in 1000 parts only 1*5 of fibrin, and 79* of corpuscles.* The organs which have been found most uniformly diseased are the spleen, the liver, and lymphatic glands. The spleen, in the great ma- jority of cases, has been enlarged, varying in weight from one to above nine pounds. The texture of the organ varied in different cases—in some being of unusual density, in others it was natural, and in a third class was more or less pulpy. In a few cases it contained yellowish masses, apparently a form of deposit, but in reality degenerated tissue. In most cases the cell and nuclear elements of the pulp were increased in amount, while the fibrous portion of the organ was apparently normal. Mere enlargement of the spleen, however, is not necessarily connected with leucocythemia, as I have met with many cases where it has been greatly hypertrophied without appreciable alteration of the blood. It has * Glasgow Journal, April 1855. Fig. 512. Colorless corpuscles slightly increased in number. Fig. 513. The same after the addition of acetic acid. 250 diam. 56 882 DISEASES OF THE BLOOD. appeared to me that in such instances the enlargement is more owino- to congestion and fibrous hypertrophy, than to increase in cell elements Next to the spleen, the liver is most commonly found diseased in leucocv- themia. In the majority of cases it is simply hypertrophied, and in a few, cirrhosed in various stages, or cancerous. The lymphatic glands ' (*)* ^ &re' als°' fre(luently enlarged. In (&) y^. G> most cases theJ are soft, presenting ,ft *. (e).° . on section a granular whitish ap- o (pi"/~*,'(^ Pearance, and yielding a copious V-^00©'^ turbid juice on pressure. In a .e"s-<%°<> few cases they were indurated, ' \*J loaded with calcareous deposits, or infiltrated with cancerous or tuber- cular exudation. The solitary and aggregated glands of Peyer have also been found hypertrophied in a few cases. The thyroid body was cancerous in one case, and evidently gave rise to the leucocythemia (Case CXCIII.); and in certain cases of bronchocele, in which the blood was examined by Drs. Holland and Neale, a similar condition was observed. Dr. Addison has also shown, in two of his cases of disease of the supra-renal capsules, that the blood was leucocythemic. Other lesions which have been occasionally found in cases of leucocythemia are evidently accidental, and in no way con- nected with that morbid state of the blood which we are now con- sidering. Relation existing between the Colorless and Colored Corpuscles of the Blood.—Many physiologists have maintained that the colored corpuscles are formed from the colorless ones; and among those who hold this opinion, some have supposed that the latter bodies are directly trans- formed into the former (Paget*). Others, again, contend that, whilst such may be the case in fishes, reptiles, and birds, in mammals the colored disc is merely the liberated nucleus of the colorless cell ("Whar- ton Jonesf). From the observations I have made on the blood cor- puscles in cases of leucocythemia, the latter appears to me to be the more correct opinion. The mode of transformation of the nucleus of the colorless cell into @©@®(D@)® fft )(D(fD€)§)t)® Fig. 516. the flattened, biconcave, colored disc, has not yet been described ; but, from the appearances I have observed, it would seem to take place in the * Kirke's Physiology, pp. 68, 69. f Lond. Phil. Trans., 1846. Fig. 514. Colorless corpuscles increased in number, and of small size. Fig. 515. The same after the addition of acetic acid. 250 diam. Fig. 516. Colorless blood-cells observed in leucocythemia, showing the different appearances of the nuclei, placed in the presumed order of their development. 500 di. LEUCOCYTHEMIA. 883 following manner :—The colorless cell may frequently be seen, on the addition of acetic acid, to have a single round nucleus. But more com- monly the nucleus is divided into two, each half having a distinct depres- sion, presenting a shadowed spot in its centre. Occasionally, before the division takes place, the nucleus becomes oval, and sometimes is elon- gated, more or less bent, and even of a horse-shoe form. Not unfre- quently the nucleus is divided into three or four granules, each having the central shadowed spot. All the appearances given, Fig. 516, have been frequently observed, and I have placed them in the presumed order of development. On two occasions the colorless bodies in the blood were of two dis- tinct sizes. The smaller were evidently free nuclei, such as could be observed within the larger. (See Figs. 522 and 523.) On examining these latter, after the addition of acetic acid, all the appearances repre- sented in the accompanying figure were observable, and these I have a b Fig. 517. again placed in the presumed order of development. On examining the lymphatic glands in the first of these cases, they were observed to con- tain the first body figured (a) in great numbers, associated with a few of the second one (b). On several occasions the blood, when crowded with colorless cor- puscles, was removed from the arm by venesection; and it was observed, that after standing twenty-four hours those variously-shaped nuclei had become of a straw color, and exactly resembled the colored discs in tint. It was immediately apparent that they had imbibed the coloring matter of the blood, leaving the cell which surrounded them perfectly trans- parent. (See Fig. 511, p. 875.) With a view of still further determining the transitional changes in the colorless cells, I performed the following experiment:—A rabbit was killed three hours after having eaten a meal. The thorax was rapidly opened, and a ligature placed round the pulmonary artery, to prevent the corpuscles coming from the thoracic duct passing into the lungs. The abdomen was then pressed gently for a few moments to favor the flow of chyle, and then a ligature placed round the large ves- sels, and the heart removed by cutting above it. On examining the blood in the right ventricle, it presented an unusually large number of color- less cells, the nuclei of which, on the addition of acetic acid, exhibited all the transition stages figured Fig. 516. On examining the blood in the left ventricle, the colorless cells were found normal in amount. This experiment was repeated with the same results. I am therefore of opinion, with Valentin and Wharton Jones, that the colored blood corpuscles in mammals are free nuclei. But I do not consider, with the latter observer, that these nuclei in mammals should necessarily proceed so far in development as to be surrounded with a Fi". 517. Presumed development of the nucleus in colorless blood-cells, in another case of leucocythemia. 500 diam. 884 DISEASES OF THE BLOOD. cell-wall,—in other words, the colored disc is not always a further phase in the evolution of the colorless cell. On the contrary, I believe that the vast majority of the colored blood discs simply reach the nuclear stage of growth before they join the circulation. Many of them, how- ever, do proceed beyond this point in development, and may be seen to have cell-walls around them. Under such circumstances, the nuclei in- crease endogenously by a process of fissiparous division, in the manner formerly described, circulate in the blood within colorless cells, and, on the solution of the cell-wall, also become colored blood discs. I have further examined the blood of birds, reptiles, and fishes, and have been enabled to observe transitional forms between the colorless and colored cell, with even greater facility than I could in man. Indeed, the attention once directed to this point,scarcely a demonstration of blood can be made in these (Turkey), animals without seeing abun- dant evidence that the latter is a transformation from the In them, however, the colorless cell, at first round, enlarges gradually, becoming oval, and color is added to it. The nuclei, also, 0 0 rv n © after the addition of acetic acid, may be ob- #©§©§ Reptile (Frog). Fig. 518. former. Frog. ©§§ served in these animals to be undergoing Turkey, fissiparous multiplication within the cells. Haddock. Thus all the appearances, Fig. 519, may readily be seen. Hence the same mode of Fis-519- endogenous development may take place in the blood-cells of all the vertebrated tribes of animals, the difference being, that whilst in birds, reptiles, and fishes, the corpuscles retain the form of nucleated cells, in mammals we find the majority of them to be free nuclei. Origin of the Blood Corpuscles.—Hewson was the first who distinctly stated that the blood corpuscles were derived from the lymphatic glands, yet few have adopted his opinions. Even Cruickshank, who wrote on the lymphatic system immediately after him, and was one of his con- temporaries, says of the lymphatic fluid in which these corpuscles swim, " that we do not know the use of this fluid."* The correctness of Hew- son's views is not even clearly admitted by his recent commentator, Mr. Gulliver,f and has been denied by most physiologists in this country; * The Anatomy of the absorbing Vessels of the Human Body. London, 4to, 1786. P. 73. f The Works of William Hewson, F. R. S., edited by George Gulliver, F. R. S. L. Printed for the Sydenham Society. Note, p. 281. Fig. 518. Cells of various sizes, colorless and colored, observed in the blood of a haddock, frog, and turkey, placed in the order of their supposed development. The three first bodies figured in each line are colorless. Fig. 519. The nuclei of the blood-cells of the haddock, frog, and turkey, as seen after the addition of acetic acid. 450 diam. LEUCOCYTHEMIA 885 and although Nasse, Wagner, Muller, and a few others, have contended that the lymph corpuscles in the blood are the same as those found in the lymphatic vessels, the mode of their origin and their functional im- portance is not even alluded to. On examining the chyle in the lacteals ramifying below the serous coat of the intestine, it is found to consist of a multitude of minute fatty molecules, floating in a fluid (See Fig. 462, p. 743). These diminish in number as the chyle progresses towards the thoracic duct, in which it is found to contain a number of free nuclei, mingled with a few others which are surrounded by a delicate cell-wall. The free nuclei may frequently be observed in mammals to present the same size and bi-concave discoid form of the colored blood corpuscles (Fig. 462, a). Moreover, on the addition of water, they in like manner become globular, and, after the fluid has been allowed to evaporate a little, assume a puckered or crenated appearance. They only differ in their want of color, and in not being partially soluble on the addition of acetic acid (Figs. 462, a; • Q - ft.ftft ,..'- -*./■©.■• .- 520, and 521). On cutting ,- *p> ^ •., ;° ^ into a well-formed lymphatic f- - '^ '">!/:(fi •^'.'.rft. .':..'. gland, and examining the juice ,"' ° q' \ :\ ? which may be squeezed from - ' -' . -,'f] ftftftT <• ^ «' it, it will "be found to contain v;;5ft ° '^ :iS-^ °-, " numerous free nuclei and nucle- •• " ' ated cells. These are evidently Fig. 520. Fig. 521. the same bodies as are found in the lymph and chyle, and those found in the latter closely resemble the colorless cells of the blood. The nucleus of these corpuscles also may frequently be observed to have undergone the fissiparous division formerly described, and to exhibit various stages of this process in chyle taken from the thoracic duct. The opinion, therefore, held by many physiologists, that the colorless cells of the blood and those of chyle or lymph are the same, and consequently that in the highest class of animals they are not formed in the blood itself, but before they are mixed with that fluid, seems to be well founded. According to Henle, the molecules of the chyle unite together in order to form the nuclei, which are afterwards surrounded by an enve- lope* These, he thinks, are delayed, and become more fully developed in the lymphatic glands.f Nasse| also states that he has seen aggrega- tions of the chyle molecules and granular bodies formed before they reach the lymphatic glands. On the other hand, it is certain that both nuclei and cells are most abundant in the glands themselves and the cases of leucocythemia prove that excess of colorless cells in the blood is not dependent upon an increase in the amount of chyle molecules, but is coincident with the enlargement of the spleen and other glandular * Anatomie Generate, par Jourdain. Tom. i. p. 45 E. + Anatomie Generale, par Jourdain. Tom. 11. p. 103. \ Wagner's Handworterbuch. Arts. Chylus and Lymphe. Fi°\ 520. Fluid chyle, mingled with water, taken from the thoracic duct of a cat three hours after it had been fed on milk. Fig. 521. The same after the addition of acetic acid. 250 diam. 886 DISEASES OF THE BLOOD. organs. It is to these, therefore, we must attribute the principal influ- ence in the formation of the colorless cells, and to them evidently we must look for the origin of the blood corpuscles. Hewson considered the lymphatic glandular system to consist of the spleen, thymus, and lymphatic glands. He believed that particles were produced in these organs, which ultimately became the blood-corpuscles, and that the spleen especially served to secrete the coloring matter which surrounded them. This doctrine, though supported to a greater or less extent by some German authors, has been repudiated by all British physiologists up to 1852. Mr. Simon* declares it to be im- possible that the globules of the thymus can enter the lymphatic or blood-vessels, on account of the limitary membrane within which they are enclosed. But that they do find their way into those vessels was shown by Hewson and Sir Astley Cooper,! who found them there; and that the colorless corpuscles of the spleen and lymphatic glands enter the blood in large numbers is proved by what occurs in leucocythemia, and by the great preponderance of these bodies at all times in splenic and portal blood. But there are other glands which must be associated with those just mentioned as part of the lymphatic system, such as the thyroid body and supra-renal capsules. The pituitary and pineal glands have also been referred to the same class of organs by Oesterlen.| Without en- tering into lengthy anatomical details of each, it may be said that all these organs resemble one another in the following particulars:— 1. They consist of a fibrous stroma, enclosing spaces lined by a structureless membrane, which spaces are filled with colorless molecules, nuclei, and cells, in all stages of development. 2. The corpuscles of all these glands resemble one another,—the nuclei corresponding in size to the colored blood-discs of mammals, and the cells corresponding to the colorless corpuscles of the blood. The very slight differences which do exist are at once explained by variations in the degree of development. 3. They have no excretory ducts, so that if the corpuscles formed in them are to leave the organs in which they originate, it can only be by the lymphatics or veins. Now, it is certain that the blood of the splenic and portal veins, even in health, is always richer in colorless corpuscles than that of the sys- temic circulation.§ It is also well known that in young animals the blood contains a larger number of the bodies than it does in their-adult condition—that is, when all these glands, including the thymus, thyroid, and supra-renal capsules, are fully developed and in a state of activity. In leucocythemia, we observe that when these glands are hypertrophied and their corpuscular elements are multiplied, the colorless corpuscles of the blood are increased in number. Two very carefully made obser- vations, however, appear to me sufficient in themselves to determine the * On the Thymus Gland, p. 91. \ Anatomy of the Thymus Gland, pp. 15 and 43. i Beitrage zur Physiologie des gesunden und kranken Organismus. Jena, 1843. § This well-known fact has been confirmed by the careful observations of Funke.— Rente's Zeitschrift, 1851, p. 172. LEUCOCYTHEMIA. 887 connection of these lymphatic glands with the cells of the blood. Thus in Case CXCIIL, where the thyroid body was enlarged, its cells and their included nuclei were considerably smaller than usual, and it was ascer- tained that the colorless bodies . p ^ in the blood and their nuclei . f^^L^- 9k * c * were smaller also (Figs. 463 @ m^L ^thin a mother cell; f whilst Kolliker| and Ecker§ (Hi w^il maintam that they are old ones, which, having fulfilled /ss*. ^"^^ VJgSr their functions in the circulation, go to the spleen, and \P3 (^ are *^ere dissolved. These large cells, containing sev- ^^ eral colored nuclei, I believe to be cells of the lympha- tic glands which, under especial circumstances, assume power of increased development, with endogenous multiplication of nuclei. They are common not only in the spleen, but in the mesenteric and other lymphatic glands, especially when hypertrophied from neigh- boring irritation, the result of inflammatory or cancerous exudations, and especially in typhoid fever. A similar increased power of devel- opment may occasionally be observed in the epithelial cells of the pul- monary air vesicles in certain kinds of pneumonia; in those covering the choroid plexus in hydrocephalus; in those of the epidermis in epithelial cancer; and in pus. On the other hand, that extravasated blood corpuscles may assemble together in groups, and subsequently be surrounded by an albuminous deposit closely resembling a cell-wall, is a fact of great pathological importance. || It is true they closely resemble the lymph cells, with multiplying nuclei, but may, I think, be separated from them by possessing more color. I have seen them not only in * Muller's Archives. Hept. 1, 1853. f Handbuch der Allgemeine und Speciellen Gewebelehre, etc., s. 53. i Mikroskopisohe Anatomie, etc. 2 Band, s. 282. 8 Wagner's Handworterbuch. Art. Blukgefassdriisen. I See Dr. Sanderson on the Metamorphosis of Colored Blood Corpuscles, etc. Monthly Journal for September and December 1851. Fig. 524. Cells with single and multiple nuclei; many of the latter in color and form exactly resemble blood globules. From the human spleen. 250 diam. LEUCOCYTHEMIA. 891 the spleen, but in other glands, and especially in the brain, following spontaneous and artificial sanguineous extravasations (See Figs. 316, 317, p. 248). But surely it will not be maintained that the normal function of the organs in which these accidental formations occur is to dissolve the blood corpuscles. Besides, from the numerous facts which have been referred to, I trust it has been made apparent that the spleen is much more probably a blood-forming than a blood-destroying gland. The view which seems to me most consistent with facts is, that the blood corpuscles are dissolved in the liquor sanguinis, and, with the effete matter absorbed from the tissues by the lymphatics, constitute blood fibrin. From the various facts which have been stated, I think we may con- clude : 1. That the blood corpuscles of vertebrate animals are originally formed in the lymphatic glandular system, and that the great majority of them, on joining the circulation, become colored in a manner that is as yet unexplained. Hence the blood corpuscles may be considered as a secretion from the lymphatic glands, although in the higher animals that secretion only becomes fully formed after it has received color by ex- posure to oxygen in the lungs. 2. That in mammalia the lymphatic glandular system is composed of the spleen, thymus, thyroid, supra-renal, pituitary, pineal, and lym- phatic glands. 3. That in fishes, reptiles, and birds, the colored blood corpuscles are nucleated cells, originating in these glands; but that in mammals they are free nuclei, sometimes derived as such from the glands, at others, developed within colorless cells. 4. That in certain hypertrophies of the lymphatic glands in man their cell elements are multiplied to an unusual extent, and under such circumstances find their way into the blood, and constitute an increase in the number of its colorless cells. A corresponding diminution in the formation of free nuclei, and consequently of colored corpuscles, must also occur. This is leucocythemia. Since the above views were published by me in 1851 they have been confirmed by observations of various kinds. Thus Holland* and Nealef have shown that in many cases of bronchocele the blood is leucocythemic. In the only two cases of supra-renal disease described by Addison in which the blood was examined, the colorless cells were increased in number. In a case of dysentery, with thickening of the mucous membrane of the small intestine, I found leucocythemia. (Case LXXXV.) Attempts have been made to divide leucocythemia into varieties. Thus Virchow speaks of a splenic and a lymphatic variety. But in this manner we might make further distinctions of a thyroid, a supra-renal, an intestinal, and a mesenteric variety, according as disease in these organs occasioned the blood lesion. Nay, more, we might speak of an hypertrophic, a tubercular, a cancerous, a dysenteric, and an anaemic form, according as we found the blood glands simply increased in size, loaded with tubercle or cancer, or associated with dysentery or anaemia. * Journal of Microscopical Science, vol. i., p. 116. | Medical Times and Gazette, vol. viii., p. 430. 892 DISEASES OF THE BLOOD. These distinctions I believe to be of no advantage, either in a scientific or practical point of view. The different blood glands contain elements which, when locally increased in number, find their way into the blood to constitute leucocythemia. They form one system of organs, and any kind of disease in them may structurally affect the blood. What appears to me, however, now a desideratum in research is, to determine why, in some cases, the blood should, and in others should not, be leucocy- themic, when these glands are diseased; and why simple anaemia, as was first shown by Bemak, should increase the number of colorless cells in the blood? In one case examined by me in the autumn of 1852, and the characteristic blood in which I had the pleasure of showing to Dr. Hanover of Copenhagen and to Dr. Sharpey of London, I unexpectedly ascertained that the microscopic examination cleared up a doubtful diagnosis. It was the case of a woman concerning whom a difference of opinion existed between two distinguished obstetricians, the one declar- ing a tumor in the left flank to be splenic, and the other that it was ovarian. I showed it to be splenic by demonstrating that the blood was crowded with colorless cells. With regard to treatment, nothing that I have yet tried has appeared to be of the slightest service directly in well-marked cases of leucocy- themia associated with distinct glandular enlargement. Iron, quinine, chloride of potassium, hydriodate of potash, and a variety of medicines given internally, with tincture of iodine applied externally, have been of no avail. But I have now seen several cases where, in the course of time and by judicious treatment, the enlarged glands have diminished, and the morbid condition of the blood become less and ultimately dis- appear. Of this, cases CXC. and CCII. are good examples. The chief indications for treatment in advanced cases, however, will be found to be furnished by accidental complications, the most common of which are diarrhoea and epistaxis, which require astringents, combined with tonics, nutrients, and stimulants, to support the vital powers. Discovery of Leucocythemia. Professor Kolliker of Wurtzburg (in Month. Journ. of Med. Science, Oct. 1854) laid before the English medical public the history of the discovery of Leucocythemia, as it is understood in Germany, from the representations of Professor Virchow. The following is my reply:— It is said by Professor Kolliker that the first observations on this subject occur in the year 1845, and take their origin from a case of disease observed by Dr. Craigie. Now, the fact is, that Dr. Craigie's case occurred in 1841; and it is admitted by Dr. Craigie himself that it would not have been published even four years afterwards but for the occurrence of mine. He says, " I kept it unpublished from the period at which it took place ; and it is published at this time, chiefly because the occurrence of a case in many, if not in all, respects similar, to another physician in the same hospital, led me to anticipate similar results, and went far to confirm my conclusions deduced from the first case."—Edin. Med. and Surg. Journal, vol. lxiv., p. 402. Professor Kolliker takes great pains to show that Dr. Craigie and myself held the same opinions as to these cases, and that in mine, which followed his, " nothing further was elucidated." On the other hand, he says Professor Virchow was the first to point out that " no signs of inflammation in the veins were any where dis- coverable," etc. Now, exactly the contrary of this is the fact. Dr. Craigie put forth two possibilities as to the cause of the blood disorder. 1st, He says, " It is barely possible that some inflammatory action had taken place in the tributary or constituent veins of the mesenteric trunks, and that the purulent matter and lymph thus formed had been conveyed into their interior with the blood, and thence into the vena cava, LEUCOCYTHEMIA. 893 heart, and vessels of the brain." 2d, He says, " Another opinion occurred to me, however, as more probable, and which various circumstances in the case induced me to regard as the most correct. Considering that the spleen had been for some time— that is, for several weeks—in a state of chronic inflammation, and taking into account the large vessels with which this organ is connected to other organs, it appeared to me that this inflammatory process, which had been continuing so long without abat- ing, subsiding, or being subdued, was at length beginning to give rise to the formation of lymph and purulent matter, and that these substances, as they were formed, were immediately taken into the veins, and thus circulating with the blood, gave rise to the peculiar assemblage of symptoms which the patient presented during the few days preceding his death." (P. 409.) From these extracts it must be clear that Dr. Craigie considered the blood disease as secondary, and dependent on the absorption of pus from an inflammatory lesion either in the mesenteric veins or spleen. The view taken up by myself was wholly different, viz., that the blood disease was primary, originating in that fluid itself, altogether independent of local inflam- mation, and especially unconnected with inflammation of the veins. This will appear from the following extracts from my paper :—" In the present state of our knowledge, then, as regards this subject, the following case seems to me particularly valuable, as it will serve to demonstrate the existence of true pus formed universally within the vascular system, independent of any local purulent collection from which it could be derived.'1'' (Pp. 413, 414.) And again, " Pus has long been considered as one, if not the most characteristic, proof of preceding acute inflammation. But in the case before us, what part was recently inflamed? There was none. Piorry and others have spoken of' an inflammation of the blood, a true hematitis; and certainly if we can imagine such a lesion, the present must be an instance of it. But it would require no labored argument to show that such a view is entirely opposed to all we know of the phenomena of inflammation:'' (P. 421.) From these passages it must be clear that I then sepa- rated the state of the blood from pre-existing inflammation in any of the tissues, which had not been done by any preceding author. I especially distinguished it from pyaemia as it was then generally understood. Thereby I established a new blood disease—one of a primary nature. I carefully described all the facts, which Virchow has only sub- sequently confirmed. I spent three entire days investigating the histological character of all the tissues in the body, and in demonstrating the important fact, that the color- less corpuscles in the blood, which I minutely described, were unconnected with inflam- mation. Notwithstanding all this, Professor Virchow has pertinaciously endeavored to persuade his countrymen that I regarded the case as one of ordinary pyaemia or purulent absorption; and Professor Kolliker, in his communication, says of these laborious researches that "nothing further was elucidated" beyond what had previ- ously been determined by Craigie and Reid. Here it should be observed that Dr. Craigie was no histologist, and had never em- ployed the microscope in the investigation of disease. To argue, then, that the dis- covery of this condition of the blood—a discovery altogether dependent on histolo- gical research—was made by him, seems absurd in the extreme. But it may be maintained that this part of the inquiry was carried out by Dr. John Reid because he stated in the register kept by him as pathologist of the Infirmary that the blood "contained globules of purulent matter and lymph." The few words now quoted constitute literally the whole of Dr. Reid's observations on the matter. They would have been buried in oblivion if I myself had not found them in the register of dissec- tions, pointed them out to Dr. Craigie, and indicated their importance. I have fre- quently conversed with Dr. Reid himself on the subjec , who had forgotten the cir- cumstance of having examined the blood microscopically in Dr. Craigie s case, or ot having made a note of it. Certainly he paid no more attention to it, or many way thought it more important than a host of other notes he made which still exist m the pathSlo-ical register, and in which some future controversialist may doubtless find many sknilar discoveries, as yet unknown. At all events it is certam that neither Dr Crai-ie nor Dr. Reid ever imagined to themselves that the ''globules of purulent matter and lymph" seen by the latter originated independent of puruknt absorption, or ever dreamed of claiming for themselves the discovery of leucocythemia. \\ ho then did make it? Certainly not Virchow, who, with Kolhker, in order to depreciate the value of my observations, claims it for these gentlemen And if none of the three m^flP it the inference undoubtedly is, that the discovery belongs to me. What then it may be asked, does' Professor Kolhker claim for his colleague? It 894 DISEASES OF THE BLOOD. cannot be the discovery of the facts, or of the existence in large numbers of colorless corpuscles in the blood, independent of inflammation. All the histological facts__ the white appearance of the blood (white blood), its independence of inflammation and its separation from all previously known pathological conditions—were minutely described by me in the paper of the 1st of October 1845, and their accuracy has been everywhere confirmed. (See Case CXCIX.) Surely this description of facts never before published, and of their connection with a new blood-disease, constitutes the discovery. On the other hand, Virchow's short and comparatively imperfect histo- logical description of a case of white blood (the white appearance of the blood being the chief point he dwelt upon) was printed in the second number for the following November, although, from the admission of Professor Kolliker, as to the practice which prevails in Germany, the actual period of its publication may have been much later. Hence all that can be claimed for Virchow amounts to this, that he put forth an opinion regarding these facts different from mine, but the possibility of which I clearly indi- cated. For, having described the peculiarities of the blood—the white coagulum, its structural characters, the colorless corpuscles, the relation to the red ones, and the absence of the inflammatory appearances in every tissue, not excepting the veins—the questions remained, What are these corpuscles ? How are they produced ? In reply, I remarked, that "with regard to the colorless corpuscles of the blood, we know of no instance where they existed in the amount, or ever presented the appearance described." From this passage Professor Kolliker draws the inference that I denied that these bodies were the colorless corpuscles of the blood. But I need scarcely point out that the passage does not fairly bear that construction. On the other hand, it clearly shows that the possibility of their being these colorless corpuscles was fully entertained. At that time the whole subject was histologically new; and having shown that the cells observed closely resembled those of pus in their structural and chemical characters, I said so, and concluded they were pus corpuscles. But having also demonstrated that they could not have been derived from any inflamed tissue, it only remained to be con- cluded that these bodies were formed in the blood system itself, constituting a primary suppuration of the blood. Here, I contend, was the real discovery, which was at that time quite new, and remains up to this hour, in my belief, a correct generalization. Whilst Professor Kolhker seems to attach no importance whatever to my careful histological examination of the blood and of the tissues, and wholly disregards the fact I was at so much pains to establish, that the colorless corpuscles I described were not dependent on inflammation, he thinks it of the greatest importance that Virchow should have stated that these corpuscles were not those of pus. To me it has always seemed of little importance by what name these bodies were designated, so long as the facts regarding them were described with exactitude. It cannot be denied that I first dis- covered and described them, and pointed out their origin in the blood itself. What histological difference there can be between pus cells independent of inflammation, originating spontaneously in the blood, and the colorless corpuscles of that fluid, I am at a loss to imagine. Yet this is the only distinction which Virchow made. But what are pus corpuscles but cells presenting certain physical characters originating in an exuded blood-plasma ? and what are the colorless corpuscles of the blood but similar cells originating in a plasma contained in the blood glands ? I have yet to learn that there is any true histological difference between them; I believe still that the only distinction is, that the same corpuscles originate in blood-plasma, sometimes outside, and sometimes within the blood system. If so, the controversy raised by Virchow, and maintained by Kolliker, is wholly one of words. Here I may mention, that, act- ing on the persuasion that the two kinds of corpuscles, hitherto separated, are really identical, I opposed the generalization of Mr. Henry Lee, which set forth that pus brought in contact with living blood caused its coagulation. In conjunction with the late Professor Barlow of the Veterinary College, I injected considerable quantities of pus into the veins of an ass, in order to determine this point. I thus increased the colorless cells in the blood of the animal without producing any coagulation or inflam- mation whatever.—(Monthly Journal, January and March 1853, pp. 80 and 212, 213.) Moreover it may be questioned, and indeed it has been questioned in a communication which I received from Professor Gluge of Brussels, and in an article by Dr. Radclifie (Half-Yearly Abstract of the Medical Sciences, vol. xvi., p. 295), whether this distinc- tion can have any real foundation. Rokitansky still maintains that the colorless cor- puscles of the blood in leucocythemia are truly those of pus, and Vidal, after a series of observations directed to this very point, has come to the conclusion that the color- LEUCOCYTHEMIA. 895 less corpuscles of the blood, those of pus and those of mucus, are the same (Gazette Hebdomadaire, Avril 11th, 1856). If so, the pretended discovery of Virchow sinks into nothing, as it is not founded on fact, but simply on opinion. As to the subsequent progress of this inquiry, I have only to express my astonish- ment at the statement made by Professor Kolhker, that in 1851, in the Monthly Journal, and that in 1852, in my separate work, I made no allusion to my former views, and did not take the slightest notice of the labors of Virchow. It is most untrue. My views regarding this disease have always been the same, but never such as Virchow and Kolliker have represented them; and so far from denying the labors of the former pathologist, I have fully set them forth, and quoted all his facts and observations. I always have and still continue to estimate highly the value of the facts he has contributed in connection with this important subject. But what he has accomplished does not entitle him to the original discovery of leucocythemia, or to the merit of giving it a place in pathology. Careful investigation into this subject will, I am satisfied, convince the candid inquirer that the discovery of leucocythemia, and the subsequent progress of ideas regarding its nature, may be divided into three epochs or stages as follows:— 1. Professor Bennett.—Discovery of a new morbid condition of the blood, con- October 1, 1845. sisting of multitudes of colorless corpuscles, resembling those of pus, associated with hypertrophy of the spleen and liver, and presenting after death peculiar white coagula. Shown to be unconnected with inflammation in any of the tissues, and especially unconnected with phlebitis. Attributed to the development of the corpus- cles in the blood itself. 2. Professor Virchow.—Confirmation of the preceding facts, but the corpuscles Series of papers from the said to be an increase in the colorless cells of the blood. 2d or 3d week of Novem- New cases, and especially one of great value, in which a ber 1845 to 1841. similar condition of the blood was associated with enlarge- ment of the lymphatic glands without hypertrophy of the spleen. Origin of the colorless cells attributed to the lymph glands; proposed name of leukhemia, or white blood. 3. Professor Bennett.—Systematic view of the whole subject. Additional facts Series of Papers, 1851, and cases, with chemical analyses of the blood. Doc- and separate work, trine that the lymphatic and other ductless glands secrete 1852. Rl. 8vo, Edinr. the blood; proposed name of leucocythemia, or white- cell blood, and the relation of this disease to other patho- logical conditions and to practical medicine pointed out. From this view of the case, it will be seen that although I claim the discovery of leucocythemia, and have given it the correct scientific name it bears, I am far from undervaluing or wishing to hide Professor Virchow's contributions to its pathology; whereas he, in order to make it appear that the origin as well as development of the whole subject is due to himself, has not hesitated to give, and circulate in Germany, the most erroneous and partial accounts of my facts and views. Since the above statement was published, Professor Virchow has continued not only ' to repeat his former errors, but to assert that his case, published at least six weeks after mine, was, in fact, the first one. Thus, in his " Gezammelte Abhandlungen," dated 1856 he says p. 155—"About the same time that my case was published, two other cases'were made known in Edinburgh," etc. He thea goes on to detail them, observing "Case 1, observed by me; Case 2, by David Craigie; Case 3, by John Hughes Bennett" Thus distinctly claiming for himself priority in observation. In the same manner Vo«-el in givin°- a report in Canstatt's Jahrbiicher of the progress of Medical Science'in 1852, part 3, on special and local pathology, puts 1st, Virchow's paper from the Archives vol. v.; 2dly, my papers in the Monthly Journal; and 3dly, my separate work. Yet what are the dates of these publications ? My papers appeared in 1851, with the first chemical analyses of the blood made by Dr W. Robertson. My separate work is dated March 1852, and Virchow's paper, with the cheimcal analyses by Pro- fessor Scherer, is dated August 1852 ! _ The French writers on this subject have declared the term leukhemia to be faulty, and adopted that of leucocythemia. Leudet,* Vidal,f and Schnepff have followed * Gazette Hebdomadaire, 21 Juillet 1855. f Idem, 15 Fevrier 1856. X Gazette Medicale de Paris, 5 Avril 1856. 896 DISEASES OP THE BLOOD. the representations of Virchow, and, in a professed historical sketch, have stated that his and my cases appeared about the same time. As if six weeks were not more than a sufficient period for the Edin. Med. and Surg. Journal to reach Berlin, and to be placed on the library table of the Royal Library there, where it might have been seen by such readers of English medical literature as Virchow undoubtedly is long before the latter published his note, in the 2d number for November of Froriep's Notizen. Schnepf (who is evidently unacquainted with my writings, and has only seen the short resume I presented to the Biological Society of Paris in 1851, at the request of my friend M. Lebert) represents Virchow's case as occurring in March, and mine in October, 1845. That is, he gives to Virchow's case the date at which mine was investigated in Edinburgh, five months before the latter occurred! The real dates are as follows:— Observed. Published. 1st Case____Prof. Bennett____March 19th, 1845____October 1st, 1845. 2d Case... .Prof. Virchow... .August 1st, 1845... .November, 2d week, 1845. 3d Case____Dr. Fuller.......Decern. 31st, 1845____July, 1846. Dr. Craigie's case must obviously be placed amongst those that occurred long before the discovery of leucocythemia was made, although, on looking back upon it, one can have no doubt that it was an example of the disease similar to a very excellent one published by Duplay, in the Archives Gen. de Medicine, 2d series, vol. xxxvi., p. 223, 1834; or the one which occurred to M. Barth in 1836, but was only published in 1856 by Vidal, when the subject was fully known. Notwithstanding the above explanations and dates, which may be easily determined to be correct, the Medical Times and Gazette, when under the editorship of Mr. Spencer Wells, continued to represent Virchow's first paper as having been published two months before mine (see No. for February 2, 1861). In a long leading article, also (see No. for October 5, 1861), other misrepresentations are published, which, as they may deceive others, require to be exposed. This is further requisite, in order to defend the reputation of Hewson, whose scientific labors, while now recognised to be of the highest merit, are completely ignored by Virchow. When I published Case CXCIX. on the 1st of October 1845, the subjects of inflammation and pyaemia were actively engaging the attention of pathologists and practical men. By some (Addison, Williams) it was maintained that an increase of the colorless cells in the blood was the cause of inflammation. Piorry talked of a haematitis or inflammation of the blood itself. Others spoke of pyaemia or purulent blood; and among these, discussions arose as to whether pus entered the blood by metastasis, by absorption, or as the result of phlebitis. The subject of inflammation, in its various aspects, had strongly engaged my attention. It was natural, therefore, when meeting with this important case, that my inquiries regarding it should, in the first instance, bear reference to its connection with that morbid process. And whereas, previously, most inquirers had associated such appearances in blood either with in- flammation or with the softened clots so accurately described by Gulliver in 1839,1 conclusively demonstrated, for the first time, that in reference to this case neither of these views was applicable. True, the cells described were called pus-corpuscles, because they were identical with them, and I spoke of suppuration of the blood; but pus and suppuration were not necessarily with me expressions that implied inflamma- tion. A pus-cell was a structure having certain characters, and a suppurative fluid was one containing pus-cells. But in saying that these might occur without inflamma- tion, an entirely new opinion was advanced, and a morbid state indicated never pre- viously suspected. In the then state of science, the important point to prove, as it appeared to me, was that there was no inflammation whatever, either primary or se- condary, no abscess anywhere, no phlebitis, no haematitis, no metastasis, no absorption of pus. As the corpuscles, therefore, were not derived from without or from the vascular walls, it followed, and this was distinctly stated, that they originated in the blood itself. I therefore called the condition of the blood " suppuration, independent of inflammation," an idea which has proved very perplexing to all those who regard suppuration as necessarily dependent on inflammation. The truth is, the mere name given to these corpuscles appeared to me (then, as it does now) to be of secondary importance, so long as the meaning attached to them is understood. Call them pus-cells, colorless cells, or leucocyths, after Robin; speak of the fluid in which they occur as a purulent fluid, as leukhaemic fluid, or as LEUCOCYTHEMIA. 897 a leucocytotical fluid (see Virchow's Cell. Pat., p. 167), the cells and the fluid are sum the same. But to show that, whatever term bo employed, the cells and fluid fojuaining them were in no way connected with inflammation, was an important siep in pathology. Still, it occurred to me that the employment of the terms pus tnd suppuration was apt to mislead persons not acquainted with histology. This »as why subsequently I proposed the expression leucocythemia, or white-cell blood, .jecause it "expresses the simple fact, or a pathological state, and involves no »neory." In Virchow's first paper (Froriep's Notizen, November 1845), which appeared six weeks after the appearance of mine, he says:—" In the older authors observations nccur here and there concerning blood which had so completely lost its color that it was likened to milk, chyle, mucus, or pus. The communication of the following case will confirm this apparently fabulous statement." Then follows the case, concerning which I need only remark, that the fact pointed out by Virchow was the color of the blood, which, as he truly says, was well known to previous writers. Hence why he called it " Leukhaemia," or white blood, vhicb he supposed to occur during life in the last stage of the disease. His words are " It must not be overlooked that cough, diarrhoea, and cedema occurred before tba epistaxis, and that the remarkable transformation of the red blood into white can- only have occurred to that degree in the latest stages, for the blood of the epistaxis was always red." Now the truth is, that in this disease the blood is never white at all during life. The coagula auer death are white or colorless, but so they are in variety of affections where coagulation takes place slowly. If, then, I committed an error in calling the state of the blood " suppuration " without inflammation, as some maintain, I must leave you to judge whether a greater error was not committed in calling it white blood, when it certainly was not white. Moreover, if my term suppuration led to confusion by assimilating the altered blood to inflammatory pus, Professor Virchow's term led also to confusion by causing it to be confounded with a state of the blood which has been recognised as white, fatty,, or chylous blood from the earliest times. Thus, then, while I endeavored to prove that a new morbid condition was inde- pendent of inflammation, Professor Virchow sought to establish the doctrine of a " white blood," which he himself says was previously known to the older writers; but it appears to me that he might, with equal correctness, have easily framed, after the notions of Hippocrates, another doctrine of black blood, the truth being, that neither the one nor the other has any foundation except on post mortem pheno- mena. The real white—that is, milky or chylous blood—had been long known, is altogether different in itself, and is owing to different causes. His views concerning epistaxis being the cause of white blood, and that the alteration must have been pro- duced shortly before death, because the bleeding from the nose was red, while they prove that the color of the blood was what principally engaged his attention, do not merit refutation. Attention, however, being now directed to the new morbid state, other cases soon occurred. The magnificent hospital of La Charite in Berlin furnished several before I could meet with one other in Edinburgh, all of which were immediately published by Professor Virchow. They tended to show that the blood disease occurred either from enlargement of the spleen or the lymphatic glands. In the Med. Zeitung, another Berlin medical journal, for August and September 1846, Nos. xxxiv.-xxxvi., he adds three cases to his own, which he finds recorded in the British medical journals. These he introduces to the German scientific world in the remarkable manner for- merly referred to :—" About the same time that I published my case, other two cases were made known in Edinburgh." He then enumerates them as follows:—Case 1. observed by me; Case 2, by David Craigie; Case 3, by John Hughes Bennett; Oase 4 by John Fuller. That some French and German writers, therefore, should have been mistaken as to the priority of observation, is not surprising. But it was reserved for the Medical Times and Gazette, so late as February 1861—long after these errors had been clearly exposed—boldly to tell its readers that Professor Virchow's original case was pubhshed two months before mine, although, in fact, it appeared six weeks afterwards. The object of this second paper by Virchow was to vindicate for the colorless blood- corpuscles a place in pathology," and to maintain that " in man there was a white as well as a red blood." I shall only say that the notion of the blood-corpuscles being a cause of disease had been previously entertained by many, especially by Addison and 57 898 DISEASES OF THE BLOOD. Williams in this country, so that they already had a place in pathology, and with regard to the white (that is chylous) blood of preceding writers being dependent on these corpuscles, the idea was then and it is now erroneous. It was in the same journal (Med. Zitung for January 184*7) that the connection between this supposed white blood and the spleen was first referred to, and it is observed that the splenic bodies are shut sacs, and he compares them to the placenta; so that, if they furnish nourish- ment to the blood-cells, the nutritive matter must transude through the membrane to nourish them. But this, he says, " is naturally a pure speculation, and only consti- tutes a basis for further researches." So that up to this time nothing positive had been made out by Virchow as to the cause of leucocythaemia. In his Archiv fiir Patholog. Anat. und Physiolog. for 1848, Professor Virchow in- serts a short abstract of the preceding papers, with another case. In the same periodi- cal for 1849 he gives one more case; and the theoretical conclusion he now arrives at as to the changes in the blood is the following:—" The blood being a constantly de- veloping, transitory tissue, with a fluid intercellular substance, always contains young elementary tissue-cells. In health, the majority of these transform themselves into specific blood-cells; the red blood-corpuscles carrying haematine. Under abnormal circumstances an interruption of development occurs, which prevents the formation of specific tissue elements, and favors the development of young cells as non-specific simple cells. These last are the so-called colorless blood-corpuscles or lymph-cor- puscles. Now, if we take a general survey of the circumstances under which a dis- tinct increase of the colorless blood-corpuscles occurs, we can distinguish three differ- ent states of the blood—1. The simple interruption of specific cells (leukaemia), with chronic enlargement of the spleen and lymphatic glands; 2. The simultaneous change in the development of the specific tissue elements of the blood, the haematine-cells and fibrine, in inflammations, pregnancy, and after repeated bleedings; 3. The in- terruption of the specific blood development connected with atrophy of the blood in typhus, in cholera, and in putrid infection (the so-called pyaemia)." I do not see that any definite information is to be obtained from these passages aa to the origin of the blood-corpuscles from the blood-glands, nor any explanation of the causes of leucocythemia. It was in January 1851 I again wrote on the subject (Monthly Journal, January to October 1851), having in the interval also been making investigations and studying the disease. In this paper I object to the term " white blood," saying it properly belongs to the milky or chylous blood formerly known; I no longer call the cells in the blood pus-cells, though still maintaining their identity with those of pus ; and propose the name leucocythemia, or white cell-blood, because, as previously stated, it" expresses the simple fact, and involves no theory; " that is, it avoids equally the errors likely to arise from the use of the term pus, suppuration, and white blood. I then reproduced all the facts known on the subject, carefully translating all Virchow's cases. The subject is illustrated by numerous woodcuts ; and several analyses of the blood are given, made by Dr. Wm. Robertson at my request. It is pointed out that mere en- largement of the spleen is not necessarily the cause of leucocythemia, as shown by hypertrophy of that organ from intermittent fever, which does not produce it. A systematic account of the symptoms, the structural and chemical composition of the blood, and the morbid anatomy of leucocythemia are detailed. Further, in a paper on the Function of the Spleen and other Lymphatic Glands as Secretors of the Blood, read to the Roya* Society of Edinburgh, Feb. 2, 1852, I fully develope these points, carefully giving to each observer his due credit in the matter. Perhaps I do not suffi- ciently dwell on the great merits of Hewson, although it is said " Hewson was the first who distinctly stated that the blood-corpuscles were derived from the lymphatic glands; yet few have adopted his opinions." And again, "Hewson considered the lymphatic glandular system to consist of the spleen, thymus, and lymphatic glands. He believed that particles were produced in these organs which ultimately became the blood-corpuscles, and that the spleen especially served to secrete the coloring matter which surrounded them. This doctrine, though supported to a greater or less extent by some German authors, has been repudiated by all British physiologists up to this time. Mr. Simon declares it to be impossible that the globules of the thymus can enter the lymphatic or blood vessels, on account of the limitary membrane within which they are enclosed." (This, we have seen, was the view of Virchow.) " But that they do find their way into these vessels was shown by Hewson and Sir Astley Cooper, who found them there; and that the colorless corpuscles of the spleen and lymphatic glands enter the blood in large numbers is proved by what occurs in LEUCOCYTHEMIA 899 leucocythaemia, and by the great preponderance of these bodies at all times in splenic and portal blood." Here I vindicate for Hewson the merit of having first pointed out the true origin of the blood-corpuscles in the spleen and lymphatic glands ; and the idea that such would ever be claimed for Virchow must appear to any reader of Hewson's works, and of Gulliver's notes on this point, to be simply preposterous. My paper concludes as follows:—" From the various facts which have been stated, I think we may conclude—1. That the blood-corpuscles of vertebrate animals are originally formed in the lymphatic glandular system ; and that the great majority of them, on joining the circulation, become colored in a manner that chemists have not yet explained. Hence the blood may be considered as a secretion from the lymphatic glands, although in the higher animals that secretion only becomes fully formed after it has received color by exposure to oxygen in the lungs. 2. That in mammalia the lymphatic glandular system is composed of the spleen, thymus, thyroid, supra-renal, pituitary, pineal, and lymphatic glands. 3. That in fishes, reptiles, and birds, the colored blood-corpuscles are nucleated cells, originating in these glands; but that in mammalia they are free nuclei, sometimes derived as such from the glands, at others developed within colorless cells. 4. That, in certain hypertrophies of the lymphatic glands their cell elements are multiplied to an unusual extent, and under such circumstances find their way into the blood, and constitute an increase in the number of its colorless ceUs; this is leucocythemia. 5. That the solution of the blood-corpuscles, conjoined with the effete matter derived from the secondary digestion of the tissues, which is not converted into albumen, constitutes blood-fibrine." Here, then, it seems to me, is a distinct theory of leucocythemia brought forward. Further, in a separate work on Leucocythemia (Edinburgh, March 1852), besides a re- print of all the previous facts, additional chapters are given on the disease viewed in relation to inflammation, to purulent infection, to phlebitis, and to other morbid condi- tions of the lymphatic glandular system, in which the subject was almost exhausted. It was in the fifth volume of his Archiv for 1853, and bearing the special date of Wurzburg, August 23, 1852 (six months after the publication of my separate work, a copy of which had been sent to him), that another long paper appeared by Virchow, claiming for himself the discovery of the whole matter ; and that he still considers himself to be the discoverer is proved by the following paragraph from his Cellular Pathology, published in English in 1861, in which he thus speaks to the countrymen of Hewson:—"A good many years elapsed (after 1845), during which I found myself pretty nearly alone in my views. It has only been by degrees, and indeed, as I am sorry to be obliged to confess, in consequence rather of physiological than pathological considerations, that people have come round to those ideas of mine, and only gradually have their minds proved accessible to the notion that, in the ordinary course of things, the lymphatic glands and the spleen are really immediately concerned in the production of the formed elements of tlie blood.'"—(Cellular Pathology, by Chance, p. 1*72, 1860.) The fifth chapter of Hewson's work, containing an account of the manner in which the red particles of the blood are formed (p. 274, Sydenham Society's edition), may be referred to for a complete refutation of this claim of Professor Virchow. Hewson says, concerning the production of the formed elements of the blood (sect. 108, op. cit., p. 285): " But if we allow the spleen to make the red part of the blood, we can readily account for the reason why the spleen may be cut out of an animal, and yet the animal survive and suffer but little inconvenience; for though the office of the spleen is lo form the red particles of the blood, yet it is not the only organ in the body capable of doing that office; for we have already proved (sections 85 and 88) that the lymphatic vessels do also form the vesicular portion; the spleen, therefore, is not the only organ capable of doing it," etc. I submit, therefore, that to Hewson (whose name is not mentioned in the Cellular Pathology), and not to Virchow, are we indebted for our knowledge of this matter. It is further to be observed that, though fully acquainted with my paper published in March 1852, in which Hewson's views are referred to, and the whole subject fully- elaborated, he continues, in the Cellular Pathology, to represent me as continuing to hold no other opinion than that leucocythaemia was pyaemia, although from the com- mencement my object was to prove there never could have been pyaemia, by which was understood absorption of pus into, and poisoning of, the blood. He says: " This conclusion of his, indeed, was not original, but was based upon the haematitis of Piorry." But in my first paper (1845) it was said of this very theory of Piorry's, " that such a view is opposed to all we know of the phenomena of inflammation,," and was thus emphatically repudiated. 90U DISEASES OF THE BLOOD. The whole arguments of the Medical Times and Gazette in 1861 consist in main- taining that, as I called the corpuscles in the blood pus, while Virchow called them colorless corpuscles, therefore the entire originality belongs to him. But Virchow now tells us (Cellular Pathology, page 155): " A pus-corpuscle can be distinguished from a colorless blood-cell by nothing else than its mode of origin. If you do not know whence it has come, you cannot say what it is; you may conceive the greatest doubt as to whether you are to regard a body of the kind as a pus or a colorless blood corpuscle. In every case of the sort the points to be considered are, where the body belongs to and where its home is. If this prove to be external to the blood, you may safely conclude that it is pus ; but if this is not the case, you have to do with blood-cells." According to this definition, a cell closely resembling a pus-cell in the saliva, inasmuch as it originates externally to the blood, is a pus and not a salivary cell. On the other hand, if a blood-vessel be full of a thick, creamy, yellow fluid, containing a multitude of cells undistinguishable from pus-cells, inasmuch as these are formed in the blood, it is not pus. According to Professor Virchow, there- fore, practical men in future, in a case of puerperal phlebitis, when they see the uterine sinuses and neighboring veins distended with pus, or surgeons, when they see the veins of the arm full of purulent matter from the bend of the elbow to the axilla, are to conclude that it is not pus ! I maintain, on the contrary, that it is pus, because it results from inflammation; that is the real question to be considered. It is only when it occurs independently of inflammation that the lesion can be said to be one of a novel character, as I first stated. But perhaps some one will say it is not pus but leucocytosis. This new word of Professor Virchow's means white cell forma- tion ; so that most embryonic transformations, the secretion of saliva, a gonorrhoea, or an abscess, is a leucocytosis, inasmuch as there is a formation of colorless cells in all of them. Such confusion of ideas and of terms can never take a place in pathology. White blood has no real existence, unless chylous blood be so called, the term being copied by Professor Virchow from the older writers. Hence, the expression leucocy- themia, or white cell-blood, is the only one which properly distinguishes the lesion in question. It follows from what has been said, therefore—1. That Professor Virchow cannot claim the discovery of leucocythemia as a matter of fact and observation, because the first case of it was carefully described and published by me, before he wrote on the subject, and separated from all known lesions, under the name of " suppuration of the blood independent of inflammation "—an idea previously unknown. 2. That he cannot claim it in consequence of calling it " white blood," as this was spoken of by the ancients, and is everywhere known as the milky or chylous blood of authors. The confusion resulting from applying this term to leucocythemia may be judged of by reference to a discussion in the Academie de Medecine, January 29, 1856, when the most distinguished chemists declared they had been familiar with it long before Professors Bennett or Virchow wrote. 3. That he cannot claim it on the ground that he has demonstrated any difference between the colorless corpuscles of the blood and pus cells, as he himself admits they are identical; and 4. That he cannot claim it on the ground that he first pointed out the blood-corpuscles, colored or colorless, to be derived from the spleen and blood-glands, as this was unquestionably made out by Hewson nearly a century ago, and was claimed for him by myself, to the exclusion of Virchow, in March 1852. At the same time, great merit is due to Professor Virchow for diligence in observa- tion and the publication of many valuable cases, which his superior advantages as pathologist to the great hospital of La Charite in Berlin enabled him to do. It ia only to be regretted that, while assisting in the development of this subject, he should have claimed for himself priority in its discovery, and have concealed and misrepre- sented the labors of those who had preceded him in the inquiry. CHLOROSIS AND ANEMIA. Case CCIIL*—Chlorosis and Anamia—Cured. History.—Lilias Ross, aet. 19, servant in a hotel—admitted October 13th, 1856. She states that menstruation commenced in her sixteenth year, and continued to recui regularly till about a year ago. It then ceased, and she experienced debility, palpita- tion with pain under the left breast, defective appetite, and discomfort after meals. * Reported by Mr. John Glen, Clinical Clerk. CHLOROSIS AND ANAEMIA. 901 On leaving off work for six weeks, her health was restored, and the catamenia returned. She again went into service, and in four months the symptoms came back. She dates the present indisposition from the last menstrual period, four weeks ago. Symptoms on Admission.—She seems in every respect well formed, not emaciated, but the skin is blanched, and of a slight greenish waxy tint. Over the chest and mammae are a few patches of pityriasis versicolor, of a faint yellowish tint. She complains of occasional palpitation. On examination, the heart's impulse is in its normal position, and is at present of natural force. There is a soft but distinct blowing murmur with the first sound, loud at the base of the organ, and audible in the course of the aorta and large arteries. Over the carotids above the clavicle, a loud double blowing is audible, which, on pressure with the stethoscope, becomes a continuous humming-top sound. Pulse 100, soft. Tongue pale and flabby, appetite defective, food causes a painful sense of weight with distention in the stomach, no vomiting or flatulence, occasional sense of constriction in the throat, bowels costive, having for some weeks been opened only by laxatives. She has frequent giddiness, rarely headache, often darkness before the eyes, no spinal irritation, but great weak- ness over the loins, and such a sense of fatigue, with heaviness in the limbs, that she has great difficulty in walking. The catamenia have not appeared at the usual period on this last occasion. They have never been profuse or accompanied by pain. Urine healthy. Respiratory system normal. R Pil. Rhei Comp. xij. Two to be taken every tlurd night. B^ Ferri Citratis> 3 j ; Syrupi Aurantii et Tr. Aurantii 5a 1 j ; Infus. Calumb. § iv. M. One table-spoonful to be taken three times a day. Progress of the Case.—October 25th.—Is improved in strength, and can walk about the ward. The heart's palpitations are easily excited. Sometimes the murmur over the carotids in the neck is of a hoarse double character, at others continuous and very loud. To encourage a return of the catamenia, four leeches ordered to be applied to the vulva, followed by a warm hipbath. November 10th.—Is gaining strength slowly on the whole, but experiences alternations in this respect—palpitations and pain under left mamma being sometimes severe, at others absent. The soft blowing murmur at base of heart has disappeared, but the humming-top sound over cervical vessels con- tinues. November 25th.—Blowing murmur at base of heart occasionally returns only after exertion. Sounds in neck less intense. No catamenia, although pediluvia, mus- tard poultices to the feet, and other means have been employed at the supposed menstrual period. December 10th.—Has continued to take the chalybeate mixture all this time, and is now strong and vigorous. A faint sound only is audible over the vessels in the neck, after exertion. Appearance healthy, appetite good, bowels regular, no headache nor nervous pain. With the exception of amenorrhcea, may be said to be quite well. Advised to go to the country for a httle. Dismissed. Commentary.—This was a well-marked case of anaemia and chlo- rosis, cured by iron, tonics, and rest. Such cases, in young women, are exceedingly common in the female wards of the Infirmary, espe- cially among the class of servants. Great discussion has occurred as to the cause of the murmurs in the heart and large blood-vessels— some maintaining their seat to be the arteries, others the veins. The arguments of Dr. Ogier Ward, who first maintained the seat of the anaemic murmur to be in the jugular vein, are generally considered to be well founded. They are—1st, The continuous murmur is often co- existent with distinct carotid impulse, which alternates with repose; 2d, It may be interrupted by pressing the vein above the stethoscope; 3d, The two murmurs may be occasionally heard by employing a small- ended stethoscope, and shifting it slightly to the right or left; 4th, It is increased by any cause which accelerates the flow of blood through the jugular vein, as during the act of inspiration, and when in the upright posture—it is diminished when there is an impediment to the venous circulation, as during expiration, the recumbent posture, and when the veins are swollen or turgid. Andral endeavored to show that the constancy of the murmur is proportionate to the diminution of corpuscles, and that it became continuous if the blood globules fell 902 DISEASES OF THE BLOOD. below 80 parts in 1000. But Dr. Davies has pointed out that the murmur is not peculiar to anaemic persons, but often exists in indivi- duals of robust health. He attributes it to friction on the inner surface of the veins, which is more or less audible according to the readiness with which their parietes take up vibrations, and the facility with which the latter are conducted to the outer surface of the body. Hence their frequency in children and young persons, and in the quick ventricular contraction, with thin blood, of the chlorotic girl, and, on the other hand, their absence during the slower circulation, and thickened condition of the tissues in adult and aged persons. At the same time there can be little doubt that the interrupted blowing at the base of the heart, over the aorta and carotids, which is synchronous with the impulse, is often arterial and not venous. Indeed, the separation of ansemic arterial and venous murmurs is frequently a matter of excessive difficulty. Some- times also, as has been well pointed out by Stokes, they are associated with organic disease, which adds to the complexity, and occasions still greater difficulty in forming a correct diagnosis. The colored corpuscles of the blood may be increased or dimi- nished in quantity, constituting Polycythcemia and Oligocythemia (Vogel). These changes may be absolute or relative. In the former case, the cor- puscles are uniformly increased or diminished throughout the body gene- rally; in the latter, this depends upon the amount of water, which, by being less or more, alters the proportion of the corpuscles to the other constituents of the blood. Becquerel drew a distinction between anaemia and chlorosis, which, on the whole, is well founded. Thus, anaemia is caused by a variety of circumstances which impoverish the blood, such as long continued hemorrhage, exhaustive discharges, star- vation, chronic diseases, certain poisons, etc.; chlorosis is induced by obscure causes connected with the nervous system, generally originating in disturbed uterine functions. In anaemia, the alteration of the blood is constant and pathognomonic; in chlorosis, it is only one of the pheno- mena, and not always present. In both diseases the physieal signs may be alike, but in anaemia the functional sound is more often in the arteries, in chlorosis in the veins. In anaemia there is constant relation between intensity of symptoms and poverty of the blood. This is not the case in chlorosis. The duration and progress of anaemia is dependent on the causes which produce it, but chlorosis is very variable, and no such evident connection is visible. The treatment of anaemia has two indi- cations—1st, To suppress the exhausting causes which occasion it; and, 2dly, By means of wine, proper nutrients, and regulated exercise, to im- prove the quality of the blood. In chlorosis, iron is the chief remedy, which should be conjoined with efforts to regulate the menstrual function. ICHORHiEMIA or (so-called) PYAEMIA. Case CCIV.*—Acute Articular Rheumatism—Multiple Abscesses in the Joints, in the Muscles, within the Cranium, etc. History.—James Lockie, aet. 17, a rope-spinner—admitted December 1, 1854. Ten days ago, when spinning ropes in the open air, he was exposed to more than usual cold and wet. Next day rigors and other febrile symptoms appeared, followed by pain, redness and swelling of the right elbow-joint. During the four following * Reported by Mr. A. W. Moore, Clinical Clerk. ICH0RH.EMIA OE PYAEMIA. 9C3 days the right wrist and ankle joints were also affected, together with both knee joints. Four days before admission the heart's action became very violent, and leeches were applied to the precordial region. The pain and swelling of the joints have continued since. Symptoms on Admission.—On admission he complained of great pain in the right wrist, ankle, and left shoulder joints, which were swollen, immovable, doughy to the feel, tender to the touch, with the integuments over them erythematous. F'rom the left shoulder-joint the swelling extended into the axilla and down the inside of the arm. Pulse 130, fuU and strong; heart's impulse violent, but no blowing murmur. The tongue coated with brown in the centre and white at the edges; no appetite; great thirst; skin hot and dry; urine turbid from excess of lithates; bowels open; no headache, and the other functions normal. Fiat venesectio ad % xiv. R: Potassce Nitratis 1 ss, Aquce § vj. Solve. § ss to be taken in half a tumblerful of water every four hours—warm saturnine lotions to the inflamed joints. Progress op the Case.—December 2d.—Little change, pulse 120, more soft, blood not buffed, but it was drawn from a small orifice. Dec. 4th.—Pain in all the joints greatly diminished; the swelling, however, continues. A blister has formed over the external malleolus of right ankle—complains of soreness in the heels. Pulse 100, of good strength. No blowing murmur with the heart's sounds. Took § j of castor-oil last night (the bowels having been constipated), which has acted copiously. Tongue dry, and covered with a brown fur. Febrile symptoms continue, with profuse dia- phoresis. On the 6th December the blister over the malleolus of right ankle burst, and gave issue to a quantity of pus. Distinct fluctuation existed over the right wrist and dorsum of the hand, which was opened by an incision, and also gave exit to a considerable quantity of pus. To omit the nitrate of potash. On the 8th, complained of pain in the back of the neck, and a bed sore was seen to be forming over the sacrum. To be placed on the water bed. From this time the pulse, which ranged from 110 to 140, lost its fulness, and became much more weak; the skin assumed a dirty yellowish or tawny hue, the typhoid febrile symptoms continued, with dry tongue and sordes, and numerous abscesses formed in the joints and various parts of the body, several of which, as soon as they became soft, were opened. A very large abscess formed over the occiput, which was opened on the 18th, and another over the manu- brium of the sternum, extending up the left side of the neck, which was opened on the 24t7i. The skin over the heels, trochanter of the right hip, and the sacrum, sloughed, notwithstanding every care taken to prevent it. On the 26th, the whole of the right lower extremity was swollen, oedematous, and white, resembling in aspect phlegmasia dolens; there were laborious breathing and great prostration. Low muttering delirium, and involuntary evacuations supervened, and he sank on the morning of the 21th. The treatment had latterly been directed, by generous diet and stimuli, to support his strength, reheve pressure on depending parts, and to dressing his sores. Sectio Cadaveris.—Seventy-two hours after death. Body greatly emaciated; a fistulous opening, the size of a shilling, existed imme- diately in front of the left sterno-clavicular articulation. Other sores, varying in size from half an inch to three inches in diameter, and laying bare the bones, existed over the right elbow, ankle, both hip-joints, right knee, and sacrum. Head.—The integument covering the occiput was separated from the skull, infil- trated with putrid pus, a great quantity of which had been evacuated by openings pre- viously made. On removing the calvarium, an abscess, containing thick yellow pus, existed between the bone and dura mater, about the centre of the occipital bone. The bone externally was somewhat carious, but internally it was healthy. No communica- tion could be traced between the external and internal abscesses. Drain healthy. Chest.__On removing the heart and aorta, a fluctuating oval swelling, about $ inch in its long diameter, was situated outside the aorta, about an inch from the aortic valves, which was distended with yellow purulent matter. The posterior portions of both inferior lobes of the lungs were condensed. On section they presented a reddish- purple color, the air vesicles filled with a soft sanguineous exudation and readily sink- ing in water. Heart healthy. Abdomen.—Kidneys slightly enlarged—on section presenting a whitish mottled appearance, without great atrophy of the secreting or encroachment on the tubular substance. Other abdominal organs healthy. Joints.—The left sterno-clavicular articulation was carious and disarticulated, with matter burrowing to considerable depths in the surrounding soft textures. The 904 diseases of the blood. right shoulder, left elbow, right wrist, both hip-joints, both knees, and both anklfl. joints, were filled with dirty purulent-looking matter, which, in several instances, more especially in the left elbow and hip joints, had infiltrated itself more than half way down the forearm and thigh. The various articular cartilages presented all stages of abrasion, softening, and ulceration; whilst the osseous textures below exhibited a carious and blackened necrosed condition. The base of the ulcer over the sacrum consisted of necrosed bone, and over the right elbow, right hip, and knee joints, bone was exposed and necrosed. The Veins were carefully examined, especially in the right inguinal region, and, with the sinuses at the base of the brain, were everywhere found healthy, and free from coagula; indeed, the blood was everywhere unusually fluid—even in the heart present- ing small, dark, and soft coagula. Microscopic Examination.—The pus consisted of molecular and granular matter with debris of disintegrated pus-cells, with the exception of the abscess within the cranium, the pus of which was normal. The cartilage covering the joints was in some places healthy, but in others its cells were enlarged, filled with secondary cells, and not unfrequently with fatty granules. Around the articulations of the joints were laminae of chronic exudations, consisting of dense amorphous matter, principally composed of minute molecules. The blood was carefully examined, and everywhere found normal. Commentary —This was a case of what is frequently called pyaemia, a disease which is not uncommon as the result of mechanical injuries or suppurative diseases. I believe it to be very rare, however, as a con- sequence of attacks of acute rheumatism, such as the symptoms and the history of this case prove it to have been. The lad was healthy and in pursuit of his ordinary occupation, when, after exposure to cold and wet, he was seized with the usual symptoms of rheumatic fever, including violent action of the heart, and on this supervened suppuration in almost all the joints, with numerous abscesses, accompanied by a low typhoid fever, under the effects of which he sank. Dr. Watson has recorded two cases singularly like it, but in them the constitutional disease was preceded by otorrhoea and abscess in the ear,* to which he theoretically ascribes the origin of the disease. In the present case there was no pri- mary abscess, no evidence of a pre-existing collection of pus before the attack of rheumatism, and I think there can be little doubt that the con- stitutional state of the blood, whatever it may have been, was dependent on the abscesses which resulted from the acute inflammation of the joints. This morbid condition, so much dreaded by surgeons and obstetri- cians, in which typhoid fever comes on after severe accidents or parturi- tion, accompanied with purulent infiltration or multiple abscesses in one or more organs, has received different explanations. The various obser- vations and experiments performed with a view of elucidating this subject in modern times have led to the four following theories;—1. That this condition is owing to an admixture of the blood with pus (pyohemia of Piorry), and that the pus-corpuscles being larger than the colored ones of blood, are arrested in the minute capillaries, and give rise to secondary abscesses. 2. That it is owing to the presence of some irri- tating body, which, not being able to escape from the economy, produces capillary phlebitis. 3. That it is dependent on a property possessed by pus of coagulating the blood. 4. That it is caused by the presence of a peculiar poison which contaminates the system. All these views have been maintained with much ingenuity, and they are all supported by experimental and clinical researches. A knowledge of the circumstances * Practice of Physic, vol. i., p. 381, 4th edition. ICHORH^EMIA OR PYJEMIA. 905 previously detailed concerning leucocythemia will enable us to criticise these doctrines from a new point of view. 1. With regard to the first theory, it must, I think, be granted by all those who have examined the blood in leucocythemia, or will study the figures I have given illustrative of that disease, that no difference whatever can be detected between the colorless cells of the blood and those of pus. Their general appearance, size, structure, and behavior, on the addition of re-agents, are identical,—indeed, so much so, that in the first case I observed in 1845 I could not resist the conclusion, that the blood was crowded with pus cells. It follows, that all explanations of purulent infection founded on the mechanical impaction of these bodies in the minute capillaries must be erroneous. Some of these colorless corpuscles have been observed much larger than ordinary pus corpuscles. In one instance many of them were twice as large; and although this may in some measure be owing to endosmosis of serum, there can be little doubt that they must have exceeded the usual size of pus cells. In Case CXCIX., also, it was observed that several of the colorless cells were larger than the average, and yet the circulation went on, and every drop of the patient's blood contained hundreds of these bodies. The first theory, then, is no longer tenable. Neither does there seem to be anything peculiar in the nature of good and laudable pus which necessarily leads it to poison the blood; for it is a matter of common observation, that large abscesses are absorbed and eliminated without occasioning so-called purulent infection. In all such cases, the pus corpuscles must, in the first instance, be disintegrated and reduced to a fluid condition; still the matter or substance of which they were composed passes into the blood. Hence, while leucocythemia proves that corpuscles, identical in form, size, structure and chemical composition with those of pu3, may float in the blood and circulate in- nocuously, the well-known fact of the absorption of abscesses demon- strates that pus, when healthy, does not possess any poisonous properties. If, then, the fever and other marked symptoms are owing to the absorp- tion of pus, it must be of pus possessing properties wholly different from those of what is called good or laudable pus. 2. The second explanation was advanced by Cruveilhier, who, on injecting mercury, ink. and other substances into the blood of a living animal, found that abscesses were formed wherever these accumulated. From hence it follows, that the impaction of certain substances in the tissues may induce local inflammation, and lead to abscesses; but that such is not the necessary result of admixture of pus with the blood, is proved not only by the previous observations, but by numerous experi- ments of Lebert* and Sedillot,f in which the animals recovered. 3. The third doctrine was advanced by Mr. Henry Lee,! ancl resulted from observing that when pus was mingled with recently-drawn blood, it coagulated more rapidly and more firmly than under ordinary circum- stances. This- observation he connected with the well-known fact, that phlebitis was often associated with coagula causing obstruction of the veins. Now it is worthy of remark, that in decided cases of leuco- cythemia the blood is more highly coagulable when drawn from the * Physiologie Pathologique, torn, i., p. 313. f De l'lnfection Purulente, p. 13, et seq. X On the Origin of Inflammation of the Veins. London, 1850. 906 DISEASES OP THE BLOOD. arm, and after death it often presents firm coagula, filling the vessels, as in Case CXCIX. Figs. 501 to 503 illustrate these colorless coagula, as observed in different parts of the body. The same occurred in Case CC.; and yet, during the life of the patient; the blood, loaded with the colorless corpuscles, rolled through the vessels without impediment or the formation of coagula. It does not follow, then, that because dead pus is mingled with recently-drawn blood about to coagulate, that there- fore it should induce coagulation of living blood in the vessels of an animal. Indeed, numerous experiments by Lebert and Sedillot show that such does not take place; for although in some cases death followed, in others the animal lived, and the pus corpuscles were dissolved.* Hence, although the fact to a certain extent must be admitted, that when pus is mingled with blood the coagulum formed is more firm, it by no means follows that it produces coagulation of living blood, and is the cause of phlebitis or purulent infection. 4. The fourth theory seems to have been maintained by A. Boyerf and Bonnet,^ who believed good pus to be innocuous, and the bad effects occasionally produced to depend on its becoming putrid, or being otherwise altered. This view was also more or less supported * In 1852, to determine this point more definitely, I performed, with the late Professor Barlow of the Veterinary College, the following experiments: Experiment 1.—The saphena vein of an ass was exposed, and a tube introduced confined by a ligature. Fresh and healthy pus was then slowly injected upwards towards the heart, from a syringe holding an ounce. A slight obstruction was now perceived, and the vein above the liga- ture could be seen to be somewhat swollen. This swelling, on being felt, was very soft; and on pressing the vein from below upwards, the mixed blood and pus was readily pushed before the finger, when all obstruction to the passage of pus from the syringe was removed. The syringe was again filled, and another ounce of pus injected, without occasioning any further local effects. The animal was then allowed to get up, and exhibited no change in its normal condition whatever. Experiment 2.—The same ass was the subject of this experiment a fortnight later, having been perfectly well in the interval. Six inches of the jugular vein in the neck were carefully dissected and exposed; and a minute aperture was then made in the upper end of the exposed vein, and the bent tube of the syringe introduced without a ligature. The coats of the vein were so trans- parent that the flowing blood could be seen through them. An ounce of fresh and perfectly healthy pus was then slowly injected downwards towards the heart, and, owing to the trans- parency of the vein, the yellow opaque fluid was seen to join the blood, to continue a few moments running side by side with the crimson current, until at length the vein became full of pus. On removing the syringe to obtain a fresh supply, the blood from above could be seen to join the pus. to continue side by side with that fluid, presenting a streaked red and white appearance, without any coagulation, until all the pus was carried forwards and downwards towards the heart, and the vein was again full of blood. Another syringeful of pus was then injected, which could once more be seen first to flow with the blood, then, as its quantity increase^, to take the place of the blood, and then, on the syringe being exhausted, to receive blood from above; the two mixing together, and continuing their course without coagulating, until once more the vein contained nothing but blood. The wound was now closed, and the animal allowed to rise, which he did without apparent suffering. He presented no unusual symptoms whatever during the next four days, when he was killed, and the parts carefully dissected. The vein was pervious, presented no thickening, nor cording or abscesses, and the external wound nearly healed. This experiment appeared to be so decisive, and so clearly opposed to the idea that the contact or mixture of pus and blood necessarily induced congulation in a living animal, that it was thought unnecessary to repeat it. With regard to the slight coagulability apparently occasioned in the first experiment, it was attributed to injecting contrary to gravity, whereby the mixed pus and blood were allowed to fall backwards and remain stationary, while the ligature prevented any flow of blood from being continued. No such phenomenon was observed in the second experiment, where no ligature was employed, and where the effect of gravity was avoided by injecting down- wards. In a communication, however, received from Dr. Henry Lee, I was informed that no ligature was employed by him. The second experiment was in its nature the same as the seventh and eighth experiments of Dr. Henry Lee, and yet none of the appearances observed by that gentleman resulted. There was no fulness or cording of the vein, no acceleration of respiration or constitutional symptoms; and after death no coagulation of the blood, no obliteration of the vein, nor local inflammation. What are the circumstances which occasioned this difference, I am not prepared to say; but the positive fact of having introduced the pus on two separate occasions, as recorded in Experiment 2, of having seen the pus ttiiy with the blood and the blood with the pus, through the transparent vein, without producing coagulation, is sufficient to negative the general proposition, that when- ever pus is mingled with blood in a living animal coagulation of the latter fluid is the inT ari»b>« result. Gazette Med. de Paris, p. 193. 1834. Ibid. p. 593. 183V. Both cited by Sedillot, Op. cit., p. 55. GLYCOH^EMIA. 907 by Darcet* and Berard,f who, in order to explain the undoubted effects of putrid substances when injected into the veins, separated pyohemia from purulent infection. But as pus corpuscles do not alone cause the symptoms, it is certainly more probable that, in all cases, there must be a toxic principle associated with pus when it proves mor- tal. Br. Millington| has shown, on repeating Mr. Lee's experiments, that putrid fluids prevent coagulation of the blood, and that the coagu- lum caused by the addition of pus is more perfect the fresher the purulent matter is. This fact is opposed to the idea that multiple abscesses are induced by the coagulation, but corresponds with what is observed after death in cases of purulent infection. When, therefore, we consider the typhoid nature of the symptoms so similar to that of certain animal poi- sons; the multiple abscesses so analogous to what occurs in glanders, plague, syphilis, variola, etc; and the undoubted fact, that the blood may be loaded with corpuscles in every respect identical with pus cells without causing these symptoms, the irresistible conclusion is, that these effects are not owing to pus in the blood, but to an animal poison. This view has been opposed on the ground that fresh pus, to all ap- pearance healthy and without odor, has yet caused the death of animals. But what sensible property distinguishes the pus of the vaccine from the small-pox pustule, and either of these from healthy pus ? And yet how different their effects when introduced into the blood! The subject of animal poisons is certainly obscure; but it is more in accordance with our actual knowledge to attribute purulent infection to such a cause than to consider it as the consequence of the mere mixture of pus with the blood, or a so-called pyohemia. This doctrine, which was first clearly put forth in my work on "Leucocythemia" in 1852, seems now to be generally adopted, and the condition of the blood has been called septicaemia (Vogel) and ichorhae- mia (Virchow). The so-called pus corpuscles, which some observers have thought they saw in the blood, are identical with the colorless cells of that fluid, and if in excess, constitute white cell blood. Virchow him- self, who has claimed so much for simply denying that leucocythemia can be pyaemia, is obliged to admit, when writing on the latter subject,^ that the diagnosis between pus and the colorless cells of the blood is very difficult, and frequently impossible. In truth, these bodies are the same, and in the majority of cases, what has been called pyaemia is not depen- dent on pus cells mingling with the blood, but on a matter derived from some kinds of pus, which poisons the blood, and occasions the secondary phenomena. GLYCOHvEMIA. Case CCV.||—Diabetes Mellitus. History.—Allan M'Clemont, aet. 32, laborer—admitted 7th June 1852. About three weeks ago, on recovering from a general rheumatic attack, he found himself much reduced in strength, and somewhat emaciated. He experienced great thirst, and passed a large quantity of urine. These symptoms have rapidly increased. * These Inaugurate. Paris, 1842. f Dictionnaire de Med., torn. 26. 1842. X Monthly Journal. November 1851. P. 486. § Gesammelte Abhandlungen. P. 653. | Reported by Mr. J. L. Brown, Clinical Clerk. 908 DISEASES OP THE BLOOD. Symptoms on Admission.—On admission, tongue moist and clean, appetite in- creased, thirst excessive, bowels rather costive, skin dry, urine very pale and slightly turbid. On heating a portion of the urine with an equal portion of" Aq. Potassae, a deep-brown color is produced. He has passed during the last 24 hours 380 oz., spec. grav. 1030, having drank 460 oz. of water in that time. Other functions performed normally. His weight was 11 stone 8 lbs. Ordered pills of Aloes and Ipecacuan, and a mixture of Inf. Quassice and Tr. Aurantii. Progress of the Case.—On the 10th June he was ordered the following diet: 3 cakes made of bran, butter, and milk, weighing half a pound; 3 eggs; 4 oz. steak for breakfast, 12 for dinner, 4 for supper; 1 cabbage ; 3 bottles of soda water; 8 oz. of lime-water; 3 oz. of wine. To have a warm bath every third night. On 15th June the amount of urine passed was diminished to 120 oz. in the day, of density 1036, and he drank during that time 150 oz. His weight was 11 stone. On the 22d lie was or- dered 4 oz. of steak additional, and another bran cake. From this time the amount of urine fluctuated from 160 to 190 oz. daily; but on the 5th July it was reduced to 150 oz., spec. grav. 1034, and his drink was 167 oz. He then weighed 11 stone 2 lbs.; but being wearied of the treatment, he insisted on going out on the 6th. Case CCVI.*—Diabetes Mellitus—Phthisis Pidmonalis—Vomica on Right Side—Death. History.—Robert Fallow, a tailor, set. 24—admitted July 8th, 1851. Last Decem- ber, when in America, was attacked with bilious fever, which continued ten weeks. Shortly afterwards he observed that the quantity of urine he passed was greatly in- creased, and that his thirst was excessive. Cough appeared six weeks ago, followed by purulent expectoration; and the skin, which had previously been remarkably dry, was now covered with copious sweat during the night. • Symptoms on Admission.—Percussion elicits no decided difference of sound on either side of the chest, but there is a much greater degree of resistance under the right clavicle than under the left. On auscultation, cavernous respiration is very dis- tinct under the right clavicle, but the sounds are dry. The vocal resonance, also, is greatly increased in the same situation, and has somewhat of a metallic character. Under the left clavicle, inspiration is harsh, and expiration prolonged. On the left side, posteriorly and inferiorly, the inspiration is everywhere harsh, with occasional cooing rales and prolongation of the expiration. The expectoration is copious, muco- purulent, and of brownish tint, without distinct traces of blood. Cough severe. Tongue furred and dry, coated near the base. Appetite good. Thirst insatiable. Sour-sweet taste in the mouth. Pulse 108, small and weak. Has voided 70 oz. of urine during the last twelve hours. The addition of liq. potassae, followed by heat, throws down a reddish-brown sediment. Skin soft and moist. Progress op the Case.—On the 11th of July gurgling was heard under the right clavicle. On the 20th there was complete loss of appetite, and repugnance to food. The urine varied since last report from 170 to 230 oz. voided in the 24 hours. Profuse sweating at night. Mucous rales heard over the whole anterior surface of chest on the right side. Vocal resonance still metallic under right clavicle, with cracked-pot sound on percussion. August 4th.—The amount of urine passed now varies from 100 to 150 oz. during 24 hours. Weakness and emaciation have greatly increased; sweating and loss of appetite continued. Died at 7 p.m. As to treatment, he was ordered a diet consisting at first of eggs, boiled meat, and stale bread and milk; pills of opium and hyoscyamus at night, and cod-liver oil in- ternally. An expectorant mixture, afterward combined with antispasmodics, was ordered, to relieve the cough. Permission to examine the body could not be obtained. Commentary.—Phthisis pulmonalis is a very common complication of diabetes in persons under 30—a circumstance which appears to me to support the pathological views formerly given as to the great importance which should be attached to derangement of the nutritive functions as a cause of the tubercular disease. An animal and oleaginous diet is indi- cated in both disorders; which, however, when present in the same indi- vidual, may easily be supposed to constitute a hopeless form of malady. * Reported by Mr. W. M. Calder, Clinical Clerk. GLYCOH^EMIA. 909 Pathology of Diabetes. The excretion of sugar in large quantities by the kidney has for a lengthened period excited the attention of pathologists, and given rise to abundant speculation. It having been shown by Mr. Macgregor of Glasgow that sugar was formed in the stomach from the digestion of food, while that principle was subsequently detected in the blood by the same observer, as well as by Ambrosiani. Maitland, and Percy—the view of Rollo was, on the whole, considered the correct one, and the treatment he proposed has been, in its main features, followed by subsequent prac- titioners. This theory supposed that the sugar formed in the stomach and alimentary canal, from the starchy and saccharine principles of the food, instead of being rapidly converted into other compounds, as Prout supposed, was absorbed into the blood, and excreted by the kidneys. The treatment based upon this theory was therefore directed to keeping up nutrition from substances which were thought incapable of being con- verted into sugar; and it is worthy of remark, that such treatment does often greatly diminish the excretion of sugar, without, however, suppress- ing it, and also ameliorates the other symptoms. Dr. Gray of Glasgow was induced to give rennet in teaspoonful doses after each meal, and pub- lished three cases, in two of which it occasioned an apparent cure. (Monthly Journal, January 1853.) He argued, that if out of the body rennet converts a solution of sugar into lactic acid, it may have a similar effect upon a solution of sugar within the body; and bearing in mind that lactic acid is found in the juice of flesh, and according to Liebig, is a supporter of the respiratory process, he considered that if sugar, formed in the body of a diabetic patient, could be converted by the rennet into lactic acid, it would be burned in the lungs; and that if a larger quantity was formed than could be consumed in this way, that portion would be excreted by the kidneys. In consequence of this ingenious theory, and the facts in its support adduced by Dr. Gray, rennet was tried in several cases admitted into the Royal Infirmary of Edinburgh, but without success. The researches of M. Bernard have given rise to other views as to the origin of diabetes. He admits that sugar may be formed in the pro- cess of digestion, and a certain amount of it may, as a result of absorption from the alimentary canal, find its way into the blood. But he has de- monstrated that, in dogs fed entirely on animal food, sugar may exist in the liver and in the blood of the hepatic vein, while it is absent in the portal vein. Moreover, he has shown that sugar is a normal secretion of the liver of all animals, from man down so low in the scale of beings as the mollusca; and that, moreover, it is secreted by the liver of the foetus. He has proved experimentally that this secreting function is increased, and diabetes produced, by irritating the eighth pair of nerves at their origin in the fourth ventricle; while, on the other hand, section of these nerves destroys its formation. I have seen M. Bernard perform these experi- ments, and have repeated them myself in this city, and have no doubt as to the accuracy of these results. That sugar does not exist normally in urine and in blood drawn from the arm is explained by its rapid decom- position in a state of health, and its excretion by the lungs. But when 910 DISEASES OF THE BLOOD. it is so increased in quantity that the lungs cannot excrete the whole of it, the remainder passes off by the kidneys; and hence diabetes. M. Bernard has also ascertained that although section of the pneumogastric nerves destroys the formation of sugar in the liver, it is restored by artificially irritating their central cut extremities; and that diabetes is produced exactly in the same manner as by irritating their origins in the brain. He was therefore led to conclude, that the nervous action neces- sary for the secretion of sugar does not originate in the brain, to be transmitted directly along the pneumogastrics, but indirectly and by reflex action; the vagi being incident nerves, the medulla oblongata the centre, and the spinal cord, communicating with the solar ganglion, the excident channel. Following out this theory, he found that whenever the respiratory function is violently stimulated sugar appears in the urine; and that whenever ether or chloroform is given a temporary dia- betes is ocasioned. He further supposes, that in the same way that the lungs thus act by reflex nervous influence on the liver, so increased ac- tion of the liver acts upon the kidney; consequently that the sugar produced in excess by one organ is excreted by the other. Hence may probably be explained the occasional temporary presence of sugar in the urine independent of the disease known as diabetes. Continuing his researches, M. Bernard arrived at the conclusion that the liver does not secrete sugar directly, but rather a substance which presents all the physical and chemical properties of hydrated starch, and which is transformed into sugar by the aid of a ferment. This substance he succeeded in separating from the liver. It has been called liver-starch, glucogene, or amyloid substance ; zoamyline, or animal starch by Rouget, and amyline by Pavy. It may readily be obtained by pouring a large quantity of crystallisable acetic acid upon a concentrated and filtered decoction of the liver. A whitish precipitate is separated, which is this glucogenic substance or amyline. The ferment Bernard presumes to exist in the blood, so that the starchy substance formed by the vital ac- tion of the liver undergoes a chemical transformation into sugar when it comes into contact with that fluid. The sugar thus formed in the blood, on arriving at the lungs, is in its turn decomposed by the oxygen of the air, and disappears. Hence the liver and the lungs are so far op- posed to one another in function that the one produces the substance out of which sugar is formed, whilst the other decomposes the sugar which in health exists in that part of the circulation only that lies between the liver and lungs. It follows that the occurrence of sugar in the circulation generally, and its presence in the urine, is probably dependent not only upon excess of hepatic, but upon diminution of pulmonary action also. It is certain that the great majority of diabetic patients die phthisical. These views of Bernard point to the importance of the observations made by Virchow, Busk, Carter, and others, as to the existence and even wide diffusion of starch corpuscles throughout the animal economy (Carter), and should stimulate organic chemists to ascertain how far chemical change in the lung may not be a cause of diabetes. According to Dr. Pavy, amyline is only transformed into sugar after death. On introducing a catheter into the right side of a living animal, and removing the venous blood, he found that it contained no sugar, but GLTCOH^EMIA. 911 that ten minutes afterwards it does. He also ascertained that the glu- cogenic function could be arrested by cold or by the injection into the portal vein of an alkaline solution (potash). In the same liver the parts which were so injected contained no sugar, while in the uninjected parts it was present. Hence, according to Pavy, all previous experiments on the dead tissues and dead blood, though correct, have led to a false inference as to what occurs in the healthy living economy. In certain diseased conditions, however, sugar is formed during life, producing dia- betes. Subsequent experiments made by Dr. Harley of Lordon showed, contrary to the views of Pavy, that sugar could be found in the liver immediately after death, and that although portal blood contained no sugar, it could be found in hepatic blood at the instant of death. Dr. Thudicum also has pointed out that when air, potash, and sugar are mixed together, the sugar is decomposed, and that in this way some of Pavy's experiments were fallacious; so that Bernard's view is still the one generally adhered to. These researches of M. Bernard explain why Hollo's treatment diminishes the excretion of sugar, by cutting off all that enters the blood through the alimentary canal. According to Traube, the intensity of the secretion of sugar varies at different times of the day, and under different circumstances. Thus it is greatly increased after meals, and is least during the night. At the commencement of the disease it is prin- cipally derived from the food; in the latter stage it is largely formed by the organism. Hence why treatment directed to the stomach does not cure, because it fails to affect the hepatic organ. Bernard's obser- vations appear to me also capable of throwing light on the good effects of opium—effects which are universally recognised—from its power of diminishing nervous irritability. No other practical results, however, are as yet derivable from them, unless the well-known symptom of dryness of the skin be connected with the cause of the disorder, in which case diaphoretics, though they have often been used with great benefit, would be more strongly indicated. Perhaps, also, exercise and a cold atmosphere, which increase the oxygenating power of. the lungs, might be of some avail. Further researches are required on these points, and it is to be hoped that practitioners, no longer exclusively directing their attention to the digestive organs, may, by new efforts, ultimately be enabled to control this singular disorder. The diet ordered in the Case CC V. is one which admits of very slight formation of sugar in the alimentary canal, and, together with opiates and the occasional use of the warm bath, constitutes the best treatment which has hitherto been adopted. Its temporary good effects were well manifested, although it proves, in conjunction with the confinement of an hospital very irksome to the patient. Indeed, m general hospitals it has been found very difficult to insure the continuance of an animal diet, and this notwithstanding the manufacture of various kinds of bread- stuffs deprived of starch, such as the gluten bread of Bouchardat, the bran biscuits of Dr. Camplin, the almond-cake 01 Dr. Pavy, and the glycerine sponge-cake of Dr. Beale. Further, it may be well questioned whether the diminution in certain symptoms so obtained really affects, in any sensible manner, the progress of the disease. We may, it is true, cut off su^ar from without, but that formed from within continues in 912 DISEASES OF THE BLOOD. excess, and ultimately exhausts the patient. Hence the idea that sugar furnished to the patient, instead of being injurious, might, by supplying him with the material the loss of which is so deleterious, serve to sup- port his strength. Piorry first showed, in a patient who was passing 17^ pints of urine daily, containing 22^ oz. of sugar, that on giving 4 oz. of sugar-candy per diem, and abstaining from drink, the amount of urine was diminished in twelve days to 4| pints, containing only 4-£ oz. of sugar.* The treatment of diabetes by sugar has been further prosecuted by Drs. Budd, Corfe, Bence, Jones, and others, with the general result of giving much relief, often diminishing the amount of sugar secreted, and occasionally improving the health. My own experience of this mode of treatment is not deficient in interest. Case CCVII.—Diabetes Mellitus—Apparent Improvement from the Use of Sugar. History.—Alexander Isset, aet. 45, tailor—admitted November 19, 1859. Four months ago he first noticed increased appetite for food, but becoming weak and inca- pable of carrying on his work, came to the Infirmary. Symptoms on Admission.—An emaciated man, with distortion of the spine and partial anchylosis of the left knee-joint. Urine pale, sp. gr. 1040, strongly impreg- nated with sugar. Great debility, otherwise healthy. Progress of the Case.—January 23d.—He has been treated with opium, which caused no relief, passing on an average 250 oz. of urine daily. To-day, while at stool, he became so faint he could scarcely speak. From this condition he was rallied by stimulants. Ordered § viij of sugar daily. March 29th.—Has been taking the sugar regularly, with an ordinary mixed diet. He has gradually become stronger, and now expresses himself as being quite well. For some weeks he has passed most of his time in the green behind the house, and is reported to be eating and drinking much less, and to be passing only from 92 to 112 oz. of urine daily. As it was discovered, however, that this man frequently passed water out of the house, and was evidently wishing to deceive, he was dismissed. Commentary.—I have given this case very shortly, because only general results were aimed at, and because nothing as to minute obser- vation could be depended on in an individual anxious to deceive us. At the same time, the fact was unquestionable that the general health on his admission was much broken down, and continued so for upwards of a month, when his debility had much augmented. Further, that on ad- ministering the sugar, not only did the strength augment, but, what is more remarkable, so far from the diabetes increasing, it was greatly diminished, although to what extent could not be ascertained. These facts appeared to me so striking that I resolved to observe the next case with great attention. Case CCVIILf—Diabetes Mellitus, treated with Sugar—Great Improve- ment for a time, followed by Cataract, Phthisis, and Death. History.—James Campbell, set. 33, a shepherd from Perthshire, married, was udmitted into the Royal Infirmary, November 29th, 1860. He has never suffered from any illness until about twelve months ago, when he first noticed a great increase in his thirst, which he satisfied by large draughts of water, or of beer when he could get it. He noticed soon afterwards that he was passing much more urine than was natural. From this time he began to lose strength, to experience dizzinesa in the head, especially on suddenly changing his posture, and to have occasional * Comptes Rendus, January 26, 1857. f Reported by Messrs. C. H. Alfrey, W. Turner, and A. Smart, Clinical Clerks. GLYCOH^EMIA. 913 cramps in the legs. Six or seven weeks ago he became so weak that he was obliged to give up all kinds of work; and since then he has rapidly lost flesh and diminished in weight, which, in health, was twelve stone. His usual diet has been oatmeal porridge morning and evening, with meat at noon. He has indulged freely in whisky, but not to great excess. He has been much exposed, in the course of his employment, to vicissitudes of the weather, but has always been well clothed. Svmptoms on Admission.—He complains of cramps in his legs, confined to the muscles of the ham and calf, which are soft and flabby. There is considerable emaciation and great muscular weakness. His weight is 8 stone 10 lbs. The skin is dry and cracked. There has been no perspiration since the commencement of the disease. Face and lips pale; an incipient arcus senilis. Pulse 52, weak. Cardiac and respiratory sounds healthy. He has no headache, but great giddiness on changing his posture. Sight and hearing somewhat impaired. His memory is also, he thinks, diminished. Answers questions slowly, but is otherwise intelligent. The tongue is covered with a moist white fur. His appetite is ravenous, and he suffers no incon- venience from the increased quantity of food he takes. Bowels regular. Passes daily an unusual quantity of urine, of faint urinous odor, sweetish taste; sp. gr. 1040, strongly impregnated with sugar, as shown by all the tests. Progrkss op the Case.—Up to the 22d of December no treatment was commenced, but observations were made to determine and regulate his food and drink, the amount of urine passed daily, and the quantity of sugar it contained. The result of these in- quiries were determined, December 23d, to be as follows:— Daily Food—Coffee, 9 oz.; milk, 16 oz.; steak, 6 oz.; tea, 9 oz.; butter, 1 oz.; eggs, 2 oz.; bread 16 oz.—the whole containing 25 solid ounces. Daily amount of water drunk—100 oz. Daily amount of urine passed—193 oz. Sp. gr. 1040. Daily amount of sugar in each English pint—600 grains. He was now ordered to take ^ lb. of brown sugar daily, which he did, partly dissolved in his coffee and milk, and partly eaten simply with a spoon. January 29th, 1861.— His general condition is greatly improved. His weight has increased to 9 stone 11 lb. His countenance is ruddy and more healthy in appearance, and his strength is much augmented. Still slight headache, but no cramps. March 23d.—Has been steadily improving in health. His weight is now 10 stone 6 lbs., and he has no pain, cramps, or other inconvenience. Drinks daily 90 oz. of water, and passes 190 oz. of urine, of the sp. gr. 1040. Dismissed. Re-admitted May 11th, 1861.—His vision and general strength have somewhat diminished, and he again feels pains and cramps in the legs. In other respects the same. Was again ordered to take the sugar. July 29th.—He left the hospital, say- ing he felt much better; but the amount of water he now drinks daily is 120 oz., and the amount of urine passed from 200 to 250. His weight was 10 stone 4 oz. Re-admitted February 22d, 1862.—Since leaving the Infirmary has not resumed his occupation, but his debility and loss of flesh have increased. His weight has fallen to 8 stone 13 lb. He now complains of cough and shortness of breath, and on ex- amining the pulmonary organs, dulness on percussion, with crepitation and increased vocal resonance on auscultation, was detected under the left clavicle. He has copious expectoration of purulent nummular sputa, and sweats profusely. Pulse 80, weak. Daily observations as to the effect of variously-mixed diets, with analyses of the urine, were made, during which it was observed that after every change a slight temporary improvement occurred. The phthisis, however, made rapid progress, and feeling him- self incapable of recovering, he left the house, greatly emaciated and weaker, June 4th. He died in the following October. Commentary.—It will be observed that in this as in the last case, the strength of the patient at first rapidly rallied, and that he gained weight under the use of sugar and a mixed diet, while the diabetic symptoms underwent little change. Phthisis at length appeared, which proved fatal. Case CCIX.*—Diabetes—Treatment by Sugar—Phthisis. History.—Mary Innes, set. 22, a servant—admitted Nov. 25th, 1862. States that she enjoyed good health till the beginning of April last, when she experienced unusual * Reported by Mr. James Rhind, Clinical Clerk. 58 914 DISEASES OF THE BLOOD. thirst, and noticed that her urine was increased in quantity. Her weakness increas. ing, she was admitted into the Infirmary. Symptoms on Admission.—Great thirst. Appetite good, but not increased. Bowels disposed to constipation. Does not sleep well. Catamenia appeared last two months ago. Urine pale, transparent, acid, sp. gr. 1047 ; answers very readily to the tests of sugar. Pulse 80, weak. Other functions normal. Progress of the Case.—Observations were made, as in the last case, to determine in the first place the ordinary condition of the patient while eating an ordinary mixed diet and drinking as much water as she pleased. § viij of sugar were then directed to be taken daily. On the 24th of January 1863 the sugar was omitted, and she was ordered the following diet:—No potatoes nor bread. To have tea without sugar 20 oz.; Dr. Pavy's almond-cake 4 oz.; milk 1-J- lbs. in the morning and evening; at din- ner 20 oz. strong beef-tea, with 4 oz. of chop, fish, or eggs. The results of these ob- servations up to the 30th of January are represented in the following table:— Averages of 7 Days. Diet. Fluids. Sp. Gr. of Urine Solids. Sugar Excreted. Weight of Patient. Taken. Passed. Taken. Passed. 1. Without Sugar-2, With Sugar 3. With Sugar -4. With Sugar -5. With Sugar 6. Without Sugar -7. Animal Diet §279 287 249 229 219 178^ 128 §243 243 203 196 178 169 103 1043 1044 1045 1045 1045 1045 1037 27 OZ. 37 31* 31 29 22 11 i 4 oz. 5* 5 6 4 2i 4 12,765 grs. 13,881 12,864 12,683 11,228 10,545 4,023 117 lbs. 116 116 116 115 115* 116 She continued in the house three months longer, during which period phthisis made its appearance, and she gradually lost strength. Many changes of diet were made, and strychnia was given for some time in small doses without effect. She left the hospital for the country on April 29th, in the last stage of phthisis. Case CCX.—Diabetes—Treated in various ivays. History.—William Mackay, set. 23, storekeeper—admitted February 5th, 1862. Has always enjoyed good health till July last, when he felt unusual thirst and hunger, also a notable increase in the amount of urine passed daily. Owing to increasing de- bility he sought admission to the Infirmary. Symptoms on Admission.—The appetite and thirst much increased. Urine pale and transparent, sweetish taste and odor, sp. gr. 1035 ; readily answers to sugar-tests. He is much emaciated. Features pinched and pale. Perspires much at night. Weighs 8 st. 3 lbs. Height 5 ft. 6 inches. All the other functions normal. Progress of the Case.—February 21st.—Patient up to this date has been living on " full mixed diet." Various kinds of treatment were tried in this case, and all thd facts recorded in the following table were carefully made by Dr. Smart, the resident physician. Averages of 10 Days. Diet, etc. Flu Taken. ids. Passed. Sp. Gr. of Urine Solids. Sugar Excreted. Weight of Patient. Taken. Passed. 1. Full Mixed Diet §369 §405 1039 56 oz. 25 oz. 17,717 grs. 115 lbs. 2. Full Mixed Diet, with 8 oz. of Sugar 404 407 1040 52 14 17,208 115 3. Full Mixed Diet 398 447 1039 62+ 18 16,615 115 4. Animal Diet 237 275 1037 24 7 10,063 113 5. Full Mixed Diet 337 356 1037 37 9 13,125 109 6. Full Mixed Diet, with 3 iss of Chlo- rate of Potash - 299 275 1033 34 3 7,437 110 7. Full Mixed Diet 328 301 1036 36 5 10,163 113 8. Full Mixed Diet, with 8 oz. of Sugar 386 328* 1036 44 8 11,083 108 His general health, when these careful observations were concluded, April 30th, had undergone no alteration. He remained in the house until the 24th of June, when he went out, at his own request, very much the same as when he first entered, but weighing 7 stone 10 lbs. CASE CCXI.—John Taylor, coal ami iron minor, aet. 33—admitted April 6th, 1864. The patient was in good health up to three months before admission. _ is emaciated, and skin dry. I'ulao 80, of moderate strength. Tongue clean ; bowels regular. No cough or expectoration. Subject to slight dimness ot sij while reading. Average daily estimate from 13th to 25th of May, while on ordinary diet. INGESTA IN OZ. URINE. SOLID EXCRETA. WEIGHT OF PATIENT. GENEEAL REMARKS. Gross Weight. Nitrogen-ous. Carboni-ferous. Total Nu-triment. Fluids. Quantity in oz. Sugar— oz. Speciflo Gravity. Other Characteristics. "Weight in oz. Lbs. 141-8 124-6 124-6 124-6 130 130 122 7-84 7 24 7-24 7*24 7-7 7-7 8 i 19-3 24-3 24-3 24-3 27-3 27-3 19 27-14 31-54 31-54 31-54 34 34 27 144-66 93-06 93-06 93-06 j 96 96 76 170 12-493 1-042 Pale, acid. No deposit. From 26th of May to 8th June (sugar 8 oz. per diem). 184 | 13-237 | 1-042 | Clear. No deposit. From 8th to 15th June. Still on sugar diet. 190-6 | 15-880 | 1-043 | Pale, acid. No deposit. From 16th to 22d June. Still on sugar diet. 167-6 | 10-983 | 1-041 | Pale, cloudy No deposit. From 25th June to 6th July (8 oz. fatty matter vice sugar, and 6 oz. of bread more per diem than before. 166 | 13-724 | 1-044 | Colorless, acid. No dep't. From 1th to 20th July. Still on the fatty diet. 165 | 11.729 | 1-042 | Colorless. No deposit. From 22d to 21th July. On the original ordinary diet. 168 | 17-374 | 1-044 | Clear, acid. No deposit. 12-4 10-5 13-0 I 12-3 12 9 11 118 111-5 113 117 118-5 124 125 Pulse 70 ; skin dry; tongue moist; bowels regular. Great dislike to sugar; feels weaker. Pulse 80. Pulse 68, of fair strength. Diarrhoea for last four days. Pulse 7 2, good strength. No diarrhoea. Still says that he is not benefited by treatment. Likes the fatty diet; feels more vigorous. Continues to improve. Dismissed 30th July, 1864. Ordinary diet, 13th May.—Boiled beef, 6 oz.; bread, 32 oz.; eggs, 4 oz.; beef-tea, 10 oz.; sweet milk, 20 oz.; butter milk, 30 oz.; tea, 20 Sugar (8 oz.per diem), was added to this diet on 26th May. Instead of sugar, 8 oz. fatty matter was given on 25th June. It consisted of butter, 4 oz.; suet, 3 oz.; cod-liver oil, 1 oz. IZiZ of eyes ^«^« <*«% ""mate from 13th to 28th May, while on ordinary diet. INGESTA IN OZ. Gross "Weight. 296-3 121-0 121-0 121-0 121 121 221 Nitrogen- ous. 12-62 20-96 20*96 20-96 20-96 20-96 12 Carboni- ferous. 21 21-23 9-32 9-32 9-32 9-32 9-32 Total Nu- triment. 33-85 30-28 30-28 30-28 30-28 30-28 33 Fluids. 262-45 90-72 90-72 90-72 90-72 90-72 187 URINE. Quantity in oz. Sugar- Specific Gravity. Other Characteristics. 319-1 21-193 1-038 Yellow col. Acid reaction From 30th of May to 8th of June, while on animal diet. 97-0 I 5-870 I 1-046 I Fetid, alkaline, phosphat- I ic deposit. From 9th to 15th June. Still on animal diet. 108-0 I 6-660 1-041 I Yellow color, with phos | phatic deposit. From 16th to 22d June. Still on animal diet. 107'7 I 7-788 I 1-044 I Yellow color. Slight | phosphatic deposit. From 23d June to 6th July. Still on animal diet. 108 | 7-622 | 1-043 | Pale, alkaline. No deposit. From 1th to 20th July. Still on animal diet. (In addition to which, Dover's powder, gr. xv. per diem.) 110 I 5-973 I 1"°41 I Yellow, pungent. Phos- I J phatic deposit. From 22d to 2lih July. On the original ordinary diet. 220 I 15*440 | 1'040 | Clear. No deposit. SOLID EXCRETA. WEIGHT OF PATIENT. Weight in oz. 13-2 13-4 14-1 14 13-5 9-6 10 Lbs. 149-4 147-7 151-5 152 155 150 GENERAL REMARKS. Pulse 90-100 ; diarrhoea ; sweats. Pulse 88 ; feels stronger ; tongue furred. Less thirsty; good appetite; bowels regular. Continuing to improve. 153-5 Do Sweating more than usual appetite good. Dismissed 30th July, 1864. ------------------Tftft TA „„ . ctonlr 4. r.7 • bread 36 oz.; eggs, 4 oz.; beef-tea, 20 oz.; sweet milk, 20 oz.; tea, 30 oz.; water, 135 oz. Ordinary diet, 13th May-BoiJ^^f, 4 oz W*0- 6 oz' . ^ 18 oz.. cabbage, 16 oz.; port wine, 3 oz.; soda-water, 30 oz.; lime-water 8 Animal or diabetic ate., .win J*ia>. > CASE CCXIIL—John Macdonald, weaver, mt. 46—admitted May 11th, 1864. He has been getting weaker for the last three or four years. _ First noticed that lie made more water than usual last summer, and found that thirst became urgent at the end of the harvest season. The patient is much emaciated »n appearance. Pulse 80, feeble. Skin dry, but occasional sweats at night. Tongue moist; bowels regular. Has a shght cough with trifling expectoration. arcus senilis. Average daily estimate from 13th to 25th May, while on ordinary diet. Long-sighted: INGESTA IN OZ. URINE. SOLID EXCRETA. WEIGHT OF PATIENT. Gross Weight. Nitrogen-ous. Carboni-ferous. Total Nu-triment. Fluids. Quantity in oz. Sugar— oz. Specific Gravity. Other Characteristics. Weight in oz. Lbs. GENERAL REMARKS. 473-1 13-16 26-20 33-36 439-74 462-3 22-683 1-032 Pale, acid. No deposit. 10-8 119-3 Pulse 80. Slight cough. From 26th May to 8th June, while or animal diet. 107-0 2339 10-81 34-20 72-80 125-4 | 7-411 | 1-039 | Clear. No deposit. From 9th to 15th June. Still on animal diet. 16-0 117-1 Appetite better. Bowels regular. Feels better. 107-0 23-39 10-81 34-20 72-80 121 | 7-880 | 1-0S8 | Pale, acid. No deposit. From 16th to 22d June. Still on animal diet. 15-4 119 Pulse 80. Less thirsty. Feels stronger, and in better spirits. 107-0 23-39 1081 34-20 72-80 UN | 6-931 | 1088 | { *££•>££ \ From 23d June to 6th July. Still on animal diet. 15 121-5 Continuing to improve. 107-0 107-0 23-39 23-39 10-81 10-81 34-20 34-20 72-80 72-80 106 | 6-621 | 1-040 1 Pale, foetid, alkaline. No deposit. From 1th to 20th July. Still on animal diet. (In addition to which, P. Doveri, gr. xv. per diem.) 110 | 6-550 | 1-044 | Pale yellow. From 22d to 21th July. On original ordinary diet. 13 12-3 122-5 122 Feels much the same. Appetite good. 383 13 26 33 350 320 | 24-704 | 1-043 1 Pale, transparent. | No deposit. 10 121 Pulse 72, feeble. Sweats less. Dismissed 30th July, 1864. Ordinary diet, on 13th May.—Beef-steak, 6 oz.; bread, 45 oz.; cabbage, 8 oz.; eggs, 4 oz.; beef-tea, 20 oz.; milk, 40 oz.; tea, 40 oz.; water, 310 oz. Animal or diabetic diet on 26th May.—Steak, 20 oz.; eggs, 6 oz.; cabbage, 16 oz.; port wine, 3 oz.; soda-water, 30 oz.; lime-water, 8 oz.; bran-caite, a oz. 918 DISEASES OF THE BLOOD. Commentary.—The last six cases of diabetes were observed, and all the facts with regard to them analysed, with the greatest care. My ob- ject was to ascertain the influence of sugar as a remedy in this disease • and it will be seen by a careful study of the results arrived at, that al- though no cure was obtained, neither were the symptoms increased. The treatment directed to cutting off sugar from the diet appears to di- minish certain symptoms without producing any influence on the pro- gress of the disease. In the two first cases in which 8 oz. of sugar were given daily (Cases CCVII. and CCV'IIL), the strength of the patients rallied wonderfully. Absence from work, rest, and the regular meals of the house, it is true, may explain this result, although even then the fact remains that the sugar did no harm whatever. In the third case (Case CCIX.), the thirst and amount of urine passed steadily diminished during the use of sugar, the other symptoms remaining much the same. In this, as well as in the preceding case, phthisis latterly appeared and caused death. In the fourth case (Case CCX.), various kinds of treat- ment were tried, an'd their influence on the ingesta, egesta, weight of the individual, and amount of sugar excreted daily, for three months, care- fully determined, without producing any advantage. The three last cases (Cases CCXI., CCXTL, and CCXIIL) were in the ward at the same time, and the most laborious observations and analyses carried on du- ring the three summer months of 1864. The results will be seen at a glance, as all the facts arrived at are tabulated. In one case (Case CCXI.), which was only of three months' standing, his health greatly improved, and he increased iu weight under the use of, first, 8 oz. sugar, then of a similar amount of fat. This I attribute to the ease being recent Cases CCXII and CCXIIL were placed on an animal diet, which caused great diminution in the thirst, hunger, amount of urine and of sugar excreted; but in no way benefited the case, as the moment they returned to an ordinary diet, the symptoms returned. The conclusion I have arrived at, from the careful trials of treatment made in these seven cases, as well as from ample experience of the effects of an animal diet, are as follows :—1st, We are still ignorant of how to cure diabetes; 2d, That the advantage to be obtained from a purely animal or non-sac- charine diet is over estimated ; 3d, That the giving sugar or employing a mixed diet produces no injury; 4th, That a non-saccharine diet dimin- ishes the symptoms, controlling the hunger and thirst, and diminishing the amount of urine and sugar passed, but does not cure the disease; 5th, On this account it should be employed as a palliative when it can be followed without injury to the health, and especially when frequent calls to micturition disturb sleep at night. CONTINUED FEYER. A state of fever may be said to exist when we find the pulse acceler- ated, the skin hot, the tongue furred, unusual thirst, and headache. These symptoms are commonly preceded by a period of indisposition varying in extent and severity, the febrile attack being marked by a rigor or sensation of cold. This rigor, though not invariably well CONTINUED FEVER. 919 characterised, is the symptom from which, when present, we date the commencement of the fever. Although fever may in one sense always be said to exist when the above group of symptoms is present, such fever may be idiopathic and essential, or symptomatic of some local lesion. It is to the former con- dition that the term fever is universally applied. Some pathologists, indeed, have endeavored to show that there is no such thing as idio- pathic or essential fever, although they have differed among themselves as to the lesion of which it is symptomatic. Intermittent fever has been supposed to be symptomatic of diseased spleen, and remittent fever of iutestinal derangement. "With regard to continued fever, some have spoken of cerebral, others of intestinal or abdominal typhus. Another class have supposed, from the occasional appearance of an eruption on the skin, that it is allied to the exanthemata. If, however, you care- fully watch the Edinburgh continued fever, you will easily satisfy your- selves that it frequently occurs independent of any of these lesions. Did we indeed adopt these views, we might, as Dr. Christison has pointed out, with more plausibility maintain the existence of a pulmonary typhus, as we observe the lungs to be much more commonly affected in this city than any other organ in the body during fever. I agree, there- fore, with those who consider continued fever as an essential disease, dependent on some unknown constitution of the blood, and occasionally accompanied or followed by various local lesions of the cranial, thoracic, or abdominal viscera, and with various eruptions on the skin. Although this may be considered as the correct general view of con- tinued fever, it cannot be denied that it assumes various forms, which have been described in different ways by authors in this and foreign countries. Considerable confusion has consequently arisen as to whether fevers observed in different places, and at various times, were identical or dissimilar in their nature ; and whether the varieties they presented were only attributable to the concomitant lesions which might be present. Any one who studies fever first in this city, and afterwards in Paris, will soon convince himself that there are at least two predominant kinds of fever;—the one called by us typhus, the other called by the French typhoid,—that is, resembling typhus. Again, those who have studied fever in Edinburgh for the last twenty years consecutively, are aware that every now and then a form of the disease is prevalent which runs a short course, but has a tendency to relapse at pretty regular periods. Lastly, there is in fever, as in most other diseases, a kind which is very slight, and soon ceases—a so-called febricula. Every practical physician is acquainted with these forms of fever; but whether they constitute varieties of the disease, which can be at all times separated, which have a distinct and invariable course, the one not being protective of the othe?, and so on, are points that are by no means determined. Dr. Jenner, in a very elaborate series of papers inserted in the " Monthly Journal" during 1849-50, has endeavored to show that febricula, relapsing fever, typhoid and typhus fevers, are four distinct diseases. He considers them, to use his own language, " as distinct from each other as are measles, scarlet fever, and small-pox, the poison 920 DISEASES OP THE BLOOD. of the one being, by no combination of circumstances, capable of pro- ducing, inducing, or exciting the others." He gives the following char- acters which, according to him, serve to distinguish these four kinds of fever.* " Febricida.—A disease attended by chilliness, alternating with sense of heat, headache, white tongue, confined bowels, high colored scanty urine, hot and dry skin, and frequent pulse, terminating in from two to seven days, and having for its cause excess, exposure, over-fatigue, etc. —i.e., the cause of febricula is not specific. " Relapsing Fever.—A disease arising from a specific cause, attended by rigors and chilliness, headache, vomiting, white tongue, epigastric ten'derness, confined bowels, enlarged liver and spleen, high colored urine, frequent pulse, hot skin, and occasionally by jaundice, and termi- nating in apparent convalescence in from five to eight days; in a week a relapse—i.e., a repetition of the symptoms present during the primary attack. ' After death, spleen and liver are found considerably enlarged ; absence of marked congestion of internal organs.' " Typhoid Fever.—A disease arising from a specific cause, attended by rigors, chilliness, headache, successive crops of rose spots, frequent pulse, sonorous rale, diarrhoea, fulness, resonance and tenderness of the abdomen, gurgling in the right iliac fossa, increased splenic dulness, delirium, dry and brown tongue, and prostration, and terminating by the thirtieth day. After death, enlargement of the mesenteric glands, disease of Peyer's patches, enlargement of the spleen, disseminated ulcerations, disseminated inflammations. " Typhus Fever.—A disease arising from a specific cause, attended * The variable amount and extension of fever at different times may be gathered from the following table, showing the number of cases which have entered the Koyal Infirmary of this city during the present century. Table showing the Annual Number of Fever Cases in the Royal Infirmary since the beginning of the century. 12Mons.toDec. 1800, 329 12 Mos. to Dec. 1822, 355 12Mons.to Oct. 1844,3339 U I ' 1801, 161 " 1823, 102 u " 1845, 683 « ' ' 1802, 156 " " 1824, 177 !< " 1846, 693 a t ' 1803, 232 " " 1825, 341 U " 1847,3688 n < ' 1804, 323 9 Mos. to Oct. 1826, 456 « " 1848,4693 u < ' 1805, 175 12 Mos. to Oct. 1827,1875 " " 1849, 726 ti < 1 1806, 95 " " 1828,2013 ll " 1850, 520 u i ' 1807, 110 " " 1829, 771 It " 1851, 959 (.< i ' 1808, 111 " " 1830, 346 It " 1852, 691 u < ' 1809, 186 " " 1831, 753 ll " 1853, 574 U ( 1 1810, 143 " " 1832,1394 " " 1854, 168 " •' ' 1811, 96 " " 1833, 878 ll " 1855, 201: " < ' 1812, 103 " " 1834, 690 It " 1856, 187 ' 1817, 485 " " 1839,1235 ll " 1861, 121 (1 < 1 1818,1546 " " 1840, 782 It " 1862, 136 << > ' 1819,1088 " " 1841,1372 (1 " 1863, 210 " ' ' 1820, 638 " " 1842, 842 It " 1864, 440 " ' 1821, 327 " " 1843,2080 : CONTINUED FEVER. 921 by rigors, chilliness, headache, mulberry rash, frequent pulse, delirium, dry brown tongue, and prostration, and terminating by the twenty-first day. After death, disseminated and extreme congestions; in young persons, enlargement of the spleen."—(Medical Times—Twentieth Paper.) Dr. Dundas, in 1852,* advanced another doctrine, entirely opposed to that of Dr. Jenner. His views on the subject of fever are essentially these:—Not only are ther.e no specific differences between the various kinds of continued fever, but there are none between continued, inter- mittent, and remittent fevers. All these disorders, according to Dr. Dundas, are essentially one disease, and may all be cured by one remedy, viz., quinine. Given in doses of ten grains, repeated at intervals of two hours, until five or six doses had been taken, he says that it arrested or cut short a continued, as it did an intermittent fever. These statements, deliberately brought forward and still maintained by Dr. Dundas, who, in Brazil and in this country, has had abundant opportunities of carry- ing out the practice, supported, moreover, by confirmatory cases, pub- lished by different medical men in Liverpool, determined me to give this practice a fair trial. During the months of November, December, and January 1851-52, I treated nineteen cases of continued fever in the clinical wards, of which four were febricula, one relapsing, three typhoid, and eleven typhus fever. In a disease so common as fever, I have thought it necessary to condense the facts as much as possible from the lengthy and accurate reports taken in the hospital books. All these cases, however, were examined with the utmost care, and all the phenomena noted, especially in reference to the two doctrines I have placed before you,—viz., those of Dr. Jenner and of Dr. Dundas. Further, to avoid repetition, I have simply stated that the quinine treatment was employed; but in every case this treatment was practised exactly in the manner recommended by the last-named physician. The effects we observed to be produced by the quinine I shall notice afterwards. FEBRICULA. Case CCXIV.f—Margaret Divine, set. 42—admitted 26th November 1851. Was attacked with rigors on the 23d, after complaining for two days before of headache, and general debility. On admission complained of pain in the limbs, and general dull pains over the body. Had no appetite, but great thirst, with a dry furred tongue; she is very subject to pyrosis; skin was hot and dry, pulse 80, strong; a slight murmur accompanied the first sound of the heart. R. Sol. Acetat. Ammon. § j; Vini Antimon. § ij ; Aquae 1 iij. M. To take one table-spoonful every four hours. November 28th.—Better to-day; pulse 72 ; a sediment filling one-fourth of the glass is deposited in the urine; still general dull pain of surface. 29th.—The general pains are gone. She feels quite well, and wishes to rise; she was now convalescent, but, owing to weakness, was not dismissed until the 15th of December. Case CCXV.f—Susan Rennie, wife of laborer, set. 49—admitted 15th of December 1851. On the 11th, was seized with severe rigors, followed by pain in the lower part * Sketches of Brazil, including new views on Fever, etc., 1852. f Reported by Mr. J. L. Brown, Clinical Clerk. -s^ 922 DISEASES OF THE BLOOD. of the back and the limbs, with frequent alternations of shivering and perspiration during the day; there was severe headache, with loss of appetite, and oppressive thirst. On admission, the tongue was slightly furred ; she had constant nausea, and vomited nearly everything she took; the skin was hot, but moist; there was no erup- tion on her person; she had a short cough, with trifling expectoration. Pulse 76, small. She continued in this state till December 19th, when, after sweating and a lengthened sleep, the fever left her, and she became convalescent, and was dismissed January 1. The treatment consisted of salines, anodynes, and stimulants. Case CCXVI.*—Thomas Stevens, set. 21, servant of a cowfeeder—admitted November 24, 1851. On the afternoon of the 23d, while engaged in his usual work, he was seized with severe rigors, headache, and pain in the back; he passed a sleep- less and uneasy night, and on attempting to resume work next day, found himself quite unable to do so, from return of the rigors, and aggravation of the headache. Had not been exposed, so far as he knew, to contagion. Had been already a patient in the house several times, having suffered from fever on three different occasions. On admission, the tongue was moist and clean, and the appetite was not much im- paired, but be had very oppressive thirst. Bowels had been irregular some time before admission. On examination of the chest, slight bronchitis of the left side was found to be present, and the sputum was thick, viscid, and muco-purulent. Skin was very dry and hot, he complained of pain in the head, principally in the frontal region, and of a throbbing character. Pulse 72, of good strength. He was ordered a full dose of castor-oil, which produced copious evacuations from the bowels ; and the fol- lowing mixture:—R Vini Anlimoni. § ss; Sol. Mur. Morph. 3i; Aquce § vss. M. Take § ss every second hour. He continued to complain of headache and geueral restlessness, and the pulse kept about 80, very full and strong, till the evening of the 25th, when he began to perspire a little; and on the forenoon of the 26th he had profuse sweating. On the 30th the antimonial solution was stopped; he improved rapidly, and was dismissed, quite well, on the 8th of December. Case CCXVIL*—Andrew Downan, set. 11, tobacco-boy—admitted January 14th, 1852. On the 11th was attacked by violent headache, lost all appetite for food, but felt exceedingly thirsty ; his skin felt very hot, and he complained of general languor and debility. Had no distinct rigors, or other premonitory symptoms. Had suffered from typhus fever about five years ago, at which time he was nine weeks in the house. On admission, tongue was dry, of florid red color, but thinly coated with a white fur, through which the red papillae were very conspicuous. No appetite, but considerable thirst; skin hot and dry, without eruption: has had no sweating since he became ill; but had profuse diaphoresis the morning after admission, when the skin became cool and moist, and the pulse fell to the natural standard. He continued two days in the house, at the end of which time he felt well enough to get out of bed, and leave the ward. He did not return. Commentary.—Febricula was the most common form of continued fever during the early part of the winter session in Edinburgh 1851-52, and the four cases above given constitute good examples of the disorder as it existed in the city during that period. It will be observed that the fever in all of them was very strong, and the rigors well marked, although the pulse was not greatly accelerated. It is impossible to dis- tinguish such cases at the commencement from typhus—a circumstance, as we shall see, of great importance, when the question comes to be, whether or no we can arrest the progress of a continued fever after it has fairly set in. It ought to be a sine qua non in all such trials not to commence the treatment until the seventh day. If, for instance, we had commenced Dr. Dundas's treatment with the above cases, we might have been led to believe in its efficacy; whereas we shall see that the typhoid and typhus cases exhibited a very different result. * Reported by Mr. J. L. Brown, Clinical Clerk, CONTINUED FEVER. 923 RELAPSING FEVER. Case CCXVLTI.*—Edward Anderson, a Swede, aet. 25, hawker—admitted Decem- ber 15th, 1851. Seized with rigors on the 8th; had great pain in the head, back, and over the body generally, and felt languid and depressed, though he was not compelled to take to bed till the 14th. On admission, tongue thickly coated; no appetite; much thirst; bowels constipated; slight pain of head; pulse 70, of natural strength ; skin hot, but moist, presenting a well-marked eruption of small roundish and oval spots of a rose-red tint, slightly raised above the surface of the skin, entirely disappearing under pressure ; widely scattered, but most abundant on the thorax. December 16th.—Slept badly; pulse 75, natural strength; sweatiug a good deal; much thirst, but total dis- inclination for food; spots more numerous. To have an effervescing draught, and six ounces of wine; also half an ounce of the following mixture at bed-time:—Tinct. Hyoscyami 3 i; Tinct. Kino 3 ij; Aq. § ij. Continued to improve daily after this date; and had no feverish accession while he remained in the ward. Was dismissed on the 29th at his own desire, as he was anxious to resume his occupation, though still rather weak. The several systems were carefully examined before dismissal, and found normal. He was re-admitted on the 5th of January 1852. Had resumed his work, but on the 1st inst., 24 days after the first rigor in the former attack, was again seized with shivering, and felt pain all over the body, but especially complained of pain in the throat, and difficulty of swallowing. There was also considerable dyspncea. On ad- mission, tongue dry and coated; mucous membrane of fauces and pharynx much con- gested, and covered with a thin layer of pus; bowels constipated; shght pain over abdomen generally, but especially in the right iliac region; voice husky and indistinct; much cough of a convulsive character; little expectoration ; no abnormal physical signs on examining the chest; pulse 110, full and hard; skin hot and flushed; and over the abdomen there were a few scattered spots of the same shape and rose-red tint as before. Vini Antimon. § i; Aq. % vj. M. § i to be taken every second hour. January 6th.—Pain on pressure in iliac region increased; had little sleep; pulse 90, full, but softer. Acetate of Ammonia, with Morphia—six leeches to right iliac region. January 8th.—(8th day, or 32d from first attack), sweating a little last night; no change in urine; no pain on pressure over the abdomen. January 9th.—Eruption very distinct, and continuing well marked for 24 hours, after which it gradually faded. January 12th.—(36th day) more feverish to-day, and complams of more pain in the throat; pulse 120, sharp and vibratory; urine natural. After this date he began to improve gradually, and was quite convalescent on February 1st. Commentary.—I have called the above a case of relapsing fever, simply because after the febrile state, counting from the first rigor, had continued for full seven days, there was complete recovery ushered in by diaphoresis. So well was this man, that he insisted on going out and resuming his occupation as a hawker. On the 24th day, however, he was again seized with all the symptoms of the primary attack, including, on both occasions, a distinct exanthematous eruption of rose-colored, lenticular, elevated spots. I am aware it may be contended that this was a case of typhoid fever. Dr. Jenner would probably so consider it on account of the eruption, the iliac tenderness, and its termination about the 30th day. Dr. Murchison has suggested to me the propriety of calling it enteric fever followed by relapse. ^ But if the circumstance of a complete recovery and a distinct relapse is to be considered as a suffi- cient cause for distinguishing a fever, it is scarcely to be conceived that these occurrences could ever be better characterised than in the above case. There is this difference, that the relapse occurred on the 21th, and not on the 14th day. This, however I have seen frequently happen in the epidemic of relapsing fever which occurred^ in this city during 1843. Though most common on the 14th day, this period was passed * Reported by Mr. W. M. Calder, Clinical Clerk. 924 DISEASES OF THE BLOOD. over, and the first relapse occurred on the 21st or 24th day. One or more relapses are not unfrequent, and it would appear as if the period of the first had been passed over. Dr. Christison has pointed out that relapsing is identical with inflam- matory fever, or the synocha of Cullen, and in his article on Fever in the Library of Medicine he has shown their similitude, especially as he had observed it in the Edinburgh epidemic of 1817 to 1820, and 1826-27. During the great epidemic of 1843-44 I had abundant opportunities of studying it, not only in others, but in my own case, having been attacked a fortnight after my appointment as Physician to the fever hospital. On that occasion Dr. Christison, who attended me, at once pronounced the disease to be the synocha, which he had seen twenty years previously, and confidently predicted the relapse, which occurred on the 14th day, when I imagined myself to be convalescent. That remarkable epidemic has been carefully described in the writings of Alison, Craigie, Cormack, Halliday, Douglas, Wardell, and others. TYPHOID FEVER TREATED BY QUININE. Case CCXIX.*—Miles Murray, aet. 25, laborer—admitted November 7, 1851. First seized with rigors on the evening of the 2d, followed by strongly-marked febrile symp- toms. No contagion. On admission, features livid and anxious; skin dry and hot; no eruption. Severe frontal headache; pain in the back, and over the whole body. Slight "subsultus tendinum." Tongue moist, but furred; no appetite, but excessive thirst. Pulse 84, full, but soft, occasionally intermittent. Short dry cough, and shght dulness on right side of chest; no unusual rales. Ordered an antimonial mixture ; six leeches to be applied to the head. November 8th.—Slept well during the night; no de- Urium. Skin still dry and hot; no eruption; tongue more dry than yesterday. Pulse 82, full, but soft. Ordered quinine, in ten-grain powders, every second hour. Nov. 9th, Vespere (7th day).—He has taken the powders regularly since ordered; no marked effect produced except on the pulse, which has come down eight or ten beats after each powder, its strength also being much reduced; there has been much sweating to- day. Still severe headache; no delirium. Urine passed this afternoon exhibits, under the microscope, amorphous lithates ; but the deposit, on standing, is inconsiderable. Nov. 11th.—Has taken in all 205 grains of the quinine. Slight tingling in the ears this morning, but only transient. Is dull and stupid to-day. Countenance has still a worn and exhausted aspect. Slight cough, and a few scattered sibilant rales on auscul- tation. Pulse 76, small, and soft. Suspend the quinine. Wine four oz., mixture with the sp. cether. nitr., and sol. ammon. acetat. Nov. 19th.—Drowsiness increased since last report, but without any other marked change. No delirium. Nov. 20th (18th day).—Urine to-day loaded with lithates. Countenance rather livid. Skin not very hot; thirst moderate. No eruption has appeared. Nov. 21st (19th day).—Feverish symptoms returned. No decided delirium, but much drowsiness, and total indifference to what is going on around him. Pulse 80, full and soft. Nov. 23d, Vespere (21st day).—Complains to-day of uneasy symptoms in epigastrium, with much nausea. Had slight vomiting in the afternoon. Nov. 24th.—Had an emetic ordered last night, which produced copious vomiting; nausea and pain in epigastrium relieved, followed by pro- fuse sweating. Nov. 30th (28th day).—Has had considerable diarrhoea during the last four days; checked by the lead and opium pills, and tannin. Slight delirium to-day; skin hot and dry; pulse 96, full, regular; cough more troublesome; bronchitic rales abundant all over the chest. December 1st.—Much sweating to-day; strength greatly prostrated; cough oppressive, and expectoration brought up with extreme difficulty ; feces and urine passed in bed. Has four ounces of wine daily, and an expectorant mixture. Dec. 6th.—Weakness increasing; almost constant sweating, but no further change. Four oz. of brandy in addition to the wine. Dec. 1th (35th day).—Was more restless than usual last night, but there is now no delirium. A bed-sore is threatening * Reported by Mr. W. M. Calder, Clinical Clerk. CONTINUED FEVER. 925 over the trochanter of the right femur. Pulse 102, small and weak. Dec. 10th.— Cough occurring in paroxysms ; weakness increasing. Dec. 12th (40th day).—Pulse to-day 130, small and vibratory; skin cool and moist; appetite little better. R; Quince Disulph. gr. iv.; Fiant pulv. tales vj. One every three hours. After taking four of the powders, the pulse fell to 102, small and jerking. Quinine stopped and brandy and wine resumed. Next day (41st of fever), he began to shiver about 3 p.m., and presented all the phenomena of a paroxysm of ague, the skin continuing pungently hot for about three hours, but without sweating. In the evening the skin was comparatively cool, and the patient felt languid and drowsy. He was ordered to resume the quinine, five grains every three hours. Dec. 14th (42d day).—No return of shivering, or febrile symptoms. After this date he began to improve steadily; and, with the exception of slight sore throat, and return of short dry cough for a few days, had not a bad symp- tom during the remainder of his stay in the house. He was dismissed perfectly well on the 19th of January, having been 73 days in the ward, and 80 days having elapsed since the occurrence of the first rigor. Commentary.—This case was observed and recorded with the greatest care, and I had no difficulty in considering it to be a case of typhoid fever, unusually prolonged, perhaps on account of the pulmonary com- plication. There were several distinct exacerbations, coming on with marked rigors, at intervals of seven days, followed by increased febrile symptoms. At one period this man's life was despaired of, the profuse sweatings, the diarrhoea, extreme prostration, with partial pneumonia, and general bronchitis, constituted symptoms of a most alarming charac- ter, through which, however, with the assistance of stimuli liberally ad- ministered, he eventually safely struggled. This also was the first case of fever in which the quinine treatment was tried. It so happened, that having ordered six doses, of ten grains each, to be administered, and not seeing him on the following day, the drug was by accident continued consecutively for eighteen doses, at intervals of two hours each. At the end of that time, no effect having been produced on the fever, it was continued in five grain doses, so that in all he took 205 grains of quinine. Notwithstanding, not only did the fever march on, but, as we have seen, the most alarming prostration was induced. No eruption could be de- tected during the whole progress of the disease, though daily looked for with the utmost care. Case CCXX.*—Marianne Howison, aet. 11—admitted January 16, 1851. Rigors appeared on the 10th, followed by febrile symptoms. Mother and sister had died im- mediately before of fever. On admission, pulse 130, full and strong; intense head- ache ; tongue dry and brown; complete anorexia, and great thirst; skin hot, no erup- tion. On the Uth, the treatment with ten-grain doses of quinine was ordered. 18th.— Five powders were given; and the report to-day is: headache gone; pulse 94, soft; skin moist and cool; tongue moist and red. On the 19th, restlessness and heat of skin returned. On the 24th, fever was as intense as when she was admitted. 25th.— Diarrhoea. 21th.—Considerable abdominal pain on pressing right iliac region; six leeches applied; § vi of wine. 31st.—Diarrhoea, which had formerly continued only twenty-four hours, has been present continuously for the last three days. February 1st. —Pulse weak; sordes on lips and tongue; intellect confused; no diarrhoea. Feb. 3d.— Pulse weak and irregular, 140; is insensible. Feb. 4th.—Very restless durmg the night; still insensible; pulse 150, small and jerking; slight haemorrhage from the gums. Died at seven p.m. Sectio Cadaveris.—Fifty-six hours after death. The mucous surface of the lower third of the small intestine was scattered over * Reported by Mr. G. A. Douglas, Clinical Clerk. 326 DISEASES OF THE BLOOD. with round and oval elevations, becoming more crowded together nearer the caecum. The former were of the size and form of a split pea, the latter varied from the size of sixpence to that of an almond. In the lower portion, some of the elevated patches were softened and sloughing, and in one or two places the sloughs had separated, forming ulcerations. The upper third of the large intestines presented also numerous round papular elevations, similar to those in the smaller intestines—the whole exhibit- ing the various well-known changes of typhoid elevations and ulcerations in a charac- teristic manner—the peritoneum corresponding to some of the ulcerations unusually congested, but there was no peritonitis. Some of the mesenteric glands enlarged and softened; other organs healthy. Commentary.—This was a well-marked case of typhoid fever, which was fatal on the twenty-fifth day ; and, on dissection, the intestinal lesion, characteristic of the disease, was discovered. Here also the quinine treat- ment was tried, with the effect at first of moderating some of the symp- toms, although on the following day they returned with increased inten- sity. As in the last case, no eruption could be discovered on this girl, though carefully looked for. It is further worthy of observation that the mother and sister had died of a similar disease. The contagious na- ture of this form of fever is still doubtful, as many insist that the intes- tinal lesion is dependent on purely endemic causes. Case CCXXI.*—John Anderson, aet. 21, sailor—admitted 29th December 1851. On the 4th of December, having been exposed to cold during his passage from Elsinore, he was seized with rigors, diarrhoea, and thirst, which continued several days. From this condition he was gradually recovering when the ship entered the harbor of Leith on the 24th. That night he was again attacked with rigors, great thirst, and diarrhoea, followed on the 27th by intense sudden pain in the abdomen, vomiting, and constipa- tion. On admission the features were shrunk and hard; skin cold and clammy; tongue red and furred; severe griping pain in the abdomen, which is shrunk; no tympanitis; bowels costive; scanty urine; no headache; pulse 126, feeble and vibrating. Twenty- four leeches were applied to the abdomen ; one opium pill every two hours. Dec. 30.— Unrelieved; mind wandering; bowels freely opened without relief; pulse very rapid, and almost imperceptible. Died at 1 p.m. Sectio Cadaveris.—Twenty-three hours after death. Peritoneum purple, congested, having flakes of lymph upon the surface. It con: tained several ounces of dirty turbid yellow fluid, having a slight fecal odor. Stomach and duodenum normal. About the middle of the jejunum a small ulcer one-half of an inch by one-eighth in size, penetrating all the coats of the intestine; edges pale and not raised. Mucous membrane of the lower part of ileum and caecum mottled with slate-colored patches; Peyer's patches prominent, and several ragged ulcers situated in their course, and in some of the solitary glands; ulcers flat, with smooth edges. Intestines contained fluid feces of a yellow color, resembling pea-soup. Commentary.—This was another undoubted case of typhoid fever, with intestinal disease, terminating by peritonitis, the result of a perfo- rating ulcer. The leading facts were communicated to me with great clearness after the boy's death by the captain of the vessel, in whose log was recorded the day of the attack, the remission, and the renewed attack on the twenty-first day. He also had observed no eruption on the skin, but of course his information on such a point was of no great value. The three cases now given have enabled you to study the principal phenomena presented by typhoid fever. With regard to its diagnosis, if you rely on the characters prominently given by Dr. Jenner, especially Reported by Mr. A. Dewar, Clinical Clerk. CONTINUED FEVER. 92V with regard to the eruption, it must be evident you will be frequently deceived. It so happens that in none of the three cases was an eruption observed, although in two it was carefully sought for; and in one of these latter the nature of the disease was placed beyond all doubt by dissection, which, after all, is the only certain proof of typhoid fever. I have been in the habit of considering the most trustworthy symptoms distinguishing this form of fever from typhus, to be the remissions; a peculiar character of the countenance expressive of abdominal pain ; the diarrhoea (especially when the stools resemble pea-soup); and marked tenderness on pressing deep down into the right iliac region. I acknow- ledge, however, that these symptoms, in the absence of an epidemic of typhoid fever, are often deceptive, even when the disease has continued beyond the thirtieth day. Typhoid fever was formerly a rare disease in Edinburgh, although common on the opposite coast of Fife, and at Linlithgow. The late Dr. John Reid used to remark, when he was pathologist to the Infirmary, that all the bodies he opened affected with typhoid ulcerations of the in- testines came from one or other of these places. On the other hand, in Paris, and in many places on the continent, it has been the prevailing form of fever. In the fever wards of this Infirmary you have the most extensive opportunities of studying typhus ; in the hospitals of the con- tinent, and especially at Paris, Berlin, Prague, and Vienna, you will see typhoid or enteric fever on a large scale. These facts serve to clear up much of the confusion which has entered into the discussions concerning continued fever by foreign and domestic writers. They also explain why the doctrine of Broussais, who conceived typhus to be gastro-enteritis— although everywhere on the continent adopted for a time—was, from the first, rejected as false by this school. At the same time there have been certain epidemics in Edinburgh during which typhoid fever has been prevalent, as there have been always cases of true typhus mixed up with the enteric fever of the continent. Thus, in the epidemic of 1847-48, an unusual number of typhoid cases were mingled with the typhus ; and I have more than once seen distinguished physicians and teachers on the continent much puzzled by finding no morbid lesion in fatal cases of fever, which, from my previous knowledge of the disease in Edinburgh, I had no difficulty in* recognising as being those of genuine typhus. During the last eight or ten years typhoid cases have been proportionally increased. TYPHUS FEVER TREATED BY QUININE. Case CCXXII.*—Mrs. Macdonald, a nurse in the Infirmary, aet. 50—admitted November 10th, 1851. Seven days ago was unusually exposed to cold, and two days afterwards experienced vomiting, pain in the back, and epigastrium, with headache, and prostration of strength, which last symptom was apparently increased by a pur- gative taken on the 8th. On admission, the skin was exceedingly hot; pulse 102, strong • tongue white and furred; great ..thirst and headache; anorexia and nausea; slight bronchitis. On the 11th, an emetic was ordered, and two hours after its opera- tion the quinine treatment to be followed. On the 12th, it is reported that she took four quinine powders of 10 grains, at intervals of two hours, but vomited the fifth. Three others however, were retained during the night, so that 70 grains have been * Reported by Mr. J. L. Brown, Clinical Clerk. 928 DISEASES OF THE BLOOD. administered. At present, she is in no way relieved. Skin hot and dry ; pulse 100, strong; tongue furred ; pains in head and epigastrium unabated. Eight leeches to be apphed to the head, and Quin. Sulph. gr. v. every two hours. Nov. 13th.—Has taken five more quinine powders. Pulse now 78, full; considerable vomiting, and pains in the epigastrium; other symptoms the same. Cold douches to the head; warm fomen- tations to the epigastrium. Pill of bismuth and opium every four hours. Nov. 14th. —Head and stomach much relieved. It is reported that last night the limbs were par- tially convulsed, and her eyes fixed, a state that lasted seven minutes. Nov. 15lh— Confusion of intellect, and restlessness. Pulse rapid and weak. § iv of wine. Nov. 11th.—Has remained in the same condition. Slight puffing of the cheeks observed on expiration. Nov. 18th.—Puffing of the cheeks more marked; unable to move the right arm; great prostration. Wine §vj. Mister to the head. Nov. 19th.—Died comatose. There has been no eruption. Commentary.—No examination of this woman's body could be ob- tained, and we are therefore in doubt as to whether an exudation had or had not taken place between the membranes of the brain. The cerebral complication, however, was in this case well marked. At first, indeed, there was nothing more than usual; but the vomiting was obstinate, and latterly the convulsion and partial paralysis indicated distinctly the organ affected. Having previously resolved to try the quinine treatment, it was given energetically in this case, but without any effect on the pro- gress of the fever. It may even be contended that it did harm, seeing we had a cerebral complication to deal with. Of this, however, at an oarly period, we could not judge, although it appears to me that the quinine practice is contra-indicated in such cases. Case CCXXIIL*—George Johnson, boot-maker, aet. 21—admitted 8th December 1851. Had severe rigors on 29th November, which were followed by the usual fever- ish symptoms. No exposure to contagion. On admission, tongue densely furred, coated, and cracked; no appetite; intense thirst; skin hot and dry; confused in his ideas, without great pain in the head; pulse 108, full. Dec. 9ih.—Slept very ill, and continues the same as yesterday. Pulse 120, full. R 01. Ricini 3 vj. Vespere.— R Sulph. Quina; 3 j; Div. in pulv. vj. One every two hours. Bowels freely moved in the afternoon; great heat of skin; much mental excitement; pulse 120, full and strong; no eruption. Dec. 10th.—Slept well; no restlessness; skin cool and moist; no headache; slight singing in the ears ; pulse 87, of good strength. Pulse rose to 88 during the day, and in the evening was full and strong. Quinine repeated; 10 grains given at first, then 13 grains every two hours. Dec. 11th.—Pulse 84, of good strength; thirst great; skin moist; no eruption. Dec. 12th (14th day)—thirst less; some appetite; no eruption; slight deposit in uriue. Improved from this time, and was dismissed January 5 th. Commentary.—This was a slight case of fever from the beginning, with no alarming symptoms, recovering on the fourteenth day. Whether this result was in any way owing to the quinine is doubtful, for, as we shall see, there were other cases very similar, in which the fever was of no longer duration. When first given, it certainly brought down the pulse, and all Jhe symptoms abated. On their return, therefore, the treatment was again had recourse to, and the dose increased to thirteen grains. On this occasion, however, no further benefit was obtained; and it appeared to me that the disease terminated with critical sediment in the urine, on the fourteenth day, in the usual manner. There was no erup- tion in this case. Case CCXXIV.f—John Craik, blacksmith, aet. 23—admitted January 5th, 1852. On December 28th, had severe rigors, followed by feverish symptoms, and during * Reported by Mr. A. Dewar, Clinical Clerk. f Reported by Mr. W. H. Broadbent, Clinical Clerk. CONTINUED FEVER. 929 the night, severe cough and much expectoration. On admission, tongue red and moist; slight sore throat; no appetite; constipation; pulse 80, of good strength; severe cough, and considerable expectoration, tinged with blood; mucous rales are heard over chest, chiefly at base of lungs; skin soft and dry; no eruption or exposure to contagion. January 1th.—Bowels freely opened ; cough very severe. Ordered saline mixture; blister to front of chest. Jan. 8th (11th day).—Very restless; delirious; drowsy and stupid; cough abated; pulse 108, weak. Vespere.—Pulse 121, quick; skin hot and dry. Quinine treatment ordered. Jan. 9th.—Skin cool and moist; pulse 90, weak; tongue moist and red; extreme deafness. Jan. 10th.—Slight diaphoresis. Jan. llih (14th day of fever).—Skin hot and dry; flushed and delirious; marked rose- colored eruption over chest and abdomen; great thirst; sordes on lips and teeth; tongue red and moist, dark in centre. Jan. 12th.—Delirious; eruption remains; sordes disappearing; skin hot and dry; cough severe; crepitation distinct at base of right lung; no dulness, but marked resonance. Ordered antimonial mixture. Jan. 13th.—Countenance flushed; pulse rapid and weak; great prostration. Blister lo right side; wine | iv. Jan. 14th.—Symptoms urgent. Jan. 15th.—Great thirst; tongue foul; crepitation gone, and the respiration is heard very indistinctly; vocal re- sonance well marked. Jan. Uth.—Improving; no dulness, nor increased vocal reso- nance ; some sibilant rales; slight deposit in urine. Steady improvement until February 20, when there was cedema of lower limbs; urine normal. Is now quite convalescent. Dismissed. Commentary.—In this case it will be observed that, although the quinine at first produced an apparent improvement, the fever, with de- lirium and the usual symptoms, shortly returned, and ran a rather pro- tracted course, owing to the pulmonary complication. Case CCXXV.*—Anne Dowie, aet. 18, servant—admitted December 10th, 1851. Seized with pain in the head, heat of skin, and general debility, Dec. 3d. Next day general pain over the body, which has continued since. On admission, pulse 120, leeble; tongue dry, red, and fissured; no appetite ; great thirst; bowels constipated; skin hot, and covered with a clammy sweat, and presenting on the chest and arms an eruption of numerous minute petechial spots, which have existed for some days; slight cough and expectoration: scattered bronchitic rales over chest. Dec. 11th. The quinine treatment was ordered. After the fifth dose of 10 grs., slight deafness, ringing in the ears; one more dose taken, after which the medicine was stopped. Dec. 12th.—Pulse 80, " excessively small and weak;" surface cooler. In the after- noon, the pulse was 86, strength much increased; skin warm and moist; tongue dry, rough and fissured; much thirst; respirations 43 in the minute; slight subsultus. 13^.—Pulse 84, of good strength; skin moist; eruption unchanged ;. lips covered with sordes ; tongue dry and cracked. On the 14th, she had smart diarrhoea, which was checked by an astringent mixture. 15th (12th day).—Appearance of patient much better; pulse 88, of good strength; eruption faded; tongue cleaner. 11th (14th day).—Cough troublesome ; a good deal of opaque dirty-looking muco-purulent mat- ter expectorated ; moist rales heard on. auscultation; thirst and anorexia continue; urine turbid, but without sediment. 19th (16th day).—Urine loaded with lithates; pa- tient improving. After this date, she recovered rapidly, and was discharged on the 15th January, quite well. Commentary.—This was a well-marked case of petechial typhus, in which the quinine treatment was tried without apparently in any way arresting its course. Although the physiological action of the drug upon the pulse was remarkably characterised. Case CCXXVI.*—Isabella Adamson, set. 20, servant—admitted December 19th, 1851, with eczema of the scalp and face. Rigors appeared January 4th, followed by febrile symptoms. Rose-colored exanthematous spots appeared on the chest and arms on the 9th On the 10th, the treatment by quinine commenced. On the Uth, the im- mediate effects of the quinine have disappeared, and the report is—Pulse 100, full * Reported by Mr. W. H. Broadbent, Clinical Clerk. 59 930 DISEASES OF THE BLOOD. and compressible; had no sleep; pain in head very intense; no sweating; tongue furred and cracked; eruption darker. 14th.—Confusion of intellect; vertigo; pulse 110, weak and intermitting; sordes on lips and tongue; subsultus tendinum. 11th. Head symptoms have been relieved by a blister; and she now began slowly to im- prove. On the 24th, pulse 80; returning appetite; sordes disappeared. On the 28th convalescent. Commentary.—This also was a remarkably well-characterized case of fever of considerable severity, evidently caught in the' ward, running its usual course, notwithstanding the quinine treatment was commenced so early as the sixth day. The eruption here presented rose-colored spots at the commencement, becoming darker afterwards. Seven cases of con- tinued fever treated by quinine have thus been recorded, which we may now contrast with six cases treated in the ordinary way. TYPHUS FEVER TREATED WITHOUT QUININE. Case CCXXVII.*—Anthony Kerracher, laborer, aet. 20—admitted November 12, 1851. On the 7th, had rigors, followed by confusion of head and general feverish symptoms. No exposure to contagion. On admission, tongue furred and white; in- tense thirst; no appetite; expression anxious, only shght headache; no eruption. November 13.—Cough severe ; dulness at lower part of left lung; cough mixture. November 20.—Feverishness gone; sleeps well; expression good. Dismissed on De- cember 8, 1851. Case OCXXVIII.*—Laurence Cochrane, laborer, aet. 43—admitted December 1st, 1851. Had first severe rigors, November 28th, followed by febrile symptoms. No exposure to contagion. Had fever six years ago. On admission, tongue furred and moist; appetite gone; constipation; pain in back and loins, and great weakness. Complains of cough; no expectoration ; chest resonant, but crepitation is heard at base of left lung; pulse 100, full and regular. December 2d.—Bowels well moved; pain unrelieved; appetite returned; no eruption. December 12th.—Fever disappeared, but very weak. Dismissed January 12th. Commentary.—Both these cases, although complicated with pulmonary disorder, ran their usual course, and in this respect resembled Case CCXXV., in which quinine was given. In neither was there any eruption. Case CCXXIX.f—Isabella Stevenson, aet. 44, washerwoman—admitted November 10th, 1851. On the 3d, first experienced pain in the head, followed by sweating, but says she had no rigors. She was in bed, complaining principally of cephalalgia, during the whole of last week. On admission, the skin is dry and hot, but at night always bathed in perspiration. No eruption; tongue furred; no appetite; thirst moderate; intense headache, with occasional stupor; pulse 120, small, threadlike. Cold to the head and stimulants. On the 12th, crepitation was heard in the left lung posteriorly. 13th.—Great dyspnoea; moist and dry rales over anterior of chest. These symptoms increased, and she died November 15th. Sectio Cadaveris.—Forty-eiyht hours after Death. Both lungs anteriorly were emphysematous in the highest degree, presenting nu- merous bullae, with deep fissures between them, with patches of collapsed lung here and there. If anything, the left lung was most affected. Posteriorly, both lungs more or less collapsed, and, on section, the lining membrane of the bronchi was deeply congested, and the tubes, on pressure, yielded an abundant muco-purulent dis- charge. Spleen small, weighing one ounce and a half; brain and other organs healthy. * Reported by Mr. A. Dewar, Clinical Clerk. f Reported by Mr. J. L. Brown, Clinical Clerk. CONTINUED FEVER, 931 Commentary.—This woman came into the ward on the same day as Case CCXXIL, the fever was equally severe, and, if anything, the headache was more violent. It was resolved to give quinine in one case and treat the other in the usual way. It so happened that both died. Case CCXXX.*—Margaret Menzies, aet. 16, servant—admitted December 28,1851. Seized with lassitude and febrile symptoms on the 22d, but without distinct rigors. On admission, pulse 100, full; tongue coated; headache and vertigo ; skin dry and hot with rose-colored elliptical spots scattered over the abdomen and chest, which ap- peared this morning; they are of mulberry color on the arms. January 1st.— Urine loaded with lithates; eruption disappeared ; skin cool; pulse natural. January 3<£—Convalescent. Case GGXXXL*—Christina Swan, servant, aet. 25—admitted December 16, 1851. Had rigors on the 14th, followed by febrile symptoms, but had headache and other premonitory symptoms on the 11th. The day before admission (15th) an eruption ap- peared on the body. On admission, pulse 120, small; tongue florid at edges, furred at the sides; no appetite; great thirst; cough. The entire surface is covered with a mulberry-colored eruption, in small crescentic patches, and though not raised, strongly resembling thatof rubeola. Eyes red and suffused, not sensitive to light. December 19th.—Was delirious last night. Mouth and teeth covered with sordes; tongue dry and cracked; is now insensible; pulse 120, small. Subsultus tendinum, bronchitis on both sides, with pneumonia on lower half of right lung. December 25th.—Since last report, constant low delirium, which to-day is somewhat diminished. Cough and ex- pectoration very troublesome. Absence of respiration from right back, with pealing vocal resonance. Pulse rapid and weak; eruption faded. Blister to head. Wine | vj. and brandy ^iv. December 29th.—No delirium, but lies in a comatose state. A lateritious sediment in the urine has appeared, and a swelling in the right parotid gland. -Pulse 98, more full. January 1st.—Consciousness returning; cough much diminished, and respiration audible in right back; skin cool. An abscess forming in the neck, below right side of jaw. From this period convalescence was slowly estab- lished ; the abscess was resolved, and she was dismissed February 2d. Commentary.—This was a very severe case of typhus, with pul- monary complication, which, however, by means of stimulants liberally given, struggled through on the twenty-first day. The eruption in her case was very peculiar, closely resembling that of rubeola, which it was maintained to be by several persons who saw it. It appeared on the second day after the rigor. But there was none of the intolerance to light, or coryza of measles; and moreover, she and her friends stated that she had previously had the disease. Under these circumstances, it is probable that it constituted the "mulberry rash" of Jenner, appearing early. Case CCXXXII.f—Bridget M'Fadyen, aet. 20, laboring woman—admitted Decem- ber 17, 1851, with psoriasis of the arms and .legs. Rigors appeared January 4, fol- lowed by slight febrile symptoms, which became fully established on the 10th. Uth.— Delirious ; face flushed; pulse 120, rather strong and jerking; no eruption. 11th.— Quite unconscious. Head shaved and blister applied. 18th.—Head relieved; pulse rapid and weak. Ordered 4 oz. of wine. On the 24lh, sediment of lithates in urine. She gradually improved after this date, and on the 26th was convalescent. No eruption. Diaynosis of Continued Fevers. On reviewing the nineteen cases of continued fever previously given, with a view of determining how far we are enabled to distinguish its * Reported by Mr. J. L. Brown, Clinical Clerk. f Reported by Mr. W. H. Broadbent, Clinical Clerk. 932 DISEASES OF THE BLOOD. varieties at an early period, it will, I think, appear that this is impossi- ble. If there be any fact connected with the disease better established than another, it is that at the onset we are unable to say whether any given case will turn out to be a febricula or a typhus, a relapsing or a typhoid fever. If you study carefully the symptoms presented by Cases CCXVL, CCXVIIL, CCXIX., and CCXXIV., you will be satisfied of this. We may, indeed, when acquainted with the prevailing type of an epidemic, often be led to guess, with more or less correctness, as to its probable course, but exactitude is impossible. Should the fever cease on the seventh day, then it may be febricula or relapsing fever. The latter is determined by the return of the disease; but I know of no cir- cumstance, beyond the type of the epidemic, which can lead us to pre- dict that event. On the other hand, should the fever continue beyond the seventh day, then we may have to do with typhus or the typhoid form. Notwithstanding all that has been said as to the means of dis- tinguishing these varieties, by means of the eruption or of the abdomi- nal symptoms, I believe that in practice it will be found to be impos- sible in several cases before the twenty-first day. In many other cases, however, the general features of the disease will enable us to speak posi- tively before that time. We have seen, in the three cases of typhoid fe- ver which have fallen under our observation, that no eruption existed in any of them. With regard to the ten cases of typhus fever also, in five there was no eruption (Cases CCXXIL, CCXXIIL, CCXXVII, CCXXVIIL, CCXXXII.),- in three there were rose spots (Cases CCXXIV., CCXXVI., CCXXX.) ; in one a mulberry or measly eruption (Case CCXXXI.) ; and in one petechia (Case CCXXV.*) Then with regard to diarrhoea, it is only diagnostic of typhoid fever after the fourteenth day. Thus, in case CCXIX. it first appeared on the twenty-eighth day, and in Case CCXX. on the fifteenth. In Case CCXXI. on the other hand, it is said to have been present from the first; but such an occurrence, however it may excite our suspicions, is far too common in all fevers to be much regarded as more particularly indicative of typhoid than of typhus fever. From all these considera- tions, the distinctions which have been made out between the various forms of continued fever are often retrospective, and only determined in the advanced stages. You cannot, therefore, be too careful in com- ing to a conclusion on this matter. * This paragraph has been criticised by a writer in the " British and Foreign Medical Review " for October 1853, who is a strong supporter of Dr. Jenner's opinion. It may be worth while, in turn, to analyse his arguments. He admits that if the eruption is not distinctive, the objection to Dr. Jenner's views would be well founded. He says, however, that in cases CCXXIH., CCXXVII., and CCXXXII., the eruption may have been absent simply on account of the youth of the patients. But typhus fever frequently attacks young people, and if the diagnostic eruption can only be depended on in persons after the age of 25, its value cannot be very great. CCXXIL is declared to be a cerebral disease, and Case CCXXVIIL a pulmonary one. Cerebral and pulmonary complications were undoubtedly there, but I can assure the critic that they were cases of typhus fever notwithstanding. Thus, however, he disposes of the five cases which are hostile to his views. Then, as to the three cases of typhus (Cases CCXXIV.. CCXXVI., and CCXXX.), with rose spots, he denies that such spots are exanthematous. But if not exanthematous, what are they ? Certainly, they were not macular or petechial. Then, because it is said in Case CCXXVI. that they became CONTINUED FEVER. 933 The investigations of Wunderlich on the continent, and of Drs. Parkes and Ringer in this country, indicate the importance of thermo- metric observations in febrile states of the body. Continuous daily determination of the temperature, according to them, exhibits fixed variations for different fevers, and forms a valuable addition to our means of diagnosis. Thus in typhus, the temperature steadily rises from 98 , the standard of health, to be above 103° in three or four days, and it declines rapidly when the fever subsides. In typhoid fever, a high temperature persists for a longer period, but peculiar remissions in the range of temperature occur, which are specially marked towards the latter end of the fever. In intermittent fever the temperature begins to be elevated during the sensation of chilliness, and having risen several degrees above 100, in a short period declines rapidly during the sweat- ing stage. In scarlatina, Dr. Ringer ^concludes that the ranges of tem- perature indicate cycles of about five days in that disease, and that a similar periodicity prevails through the complications and sequelae. This requires confirmation. As a general rule, it may be stated that in scar- latina the temperature attains its maximum from the second to the fourth day; it then declines rapidly with the pulse until convalescence. The introduction of thermometric investigation as an element of clin- ical research being of comparatively recent date, there are many points of interest still undetermined. From some observations made by Mr. T. Evans, one of my clinical clerks in 1864, it would appear that in typhus fever the temperature attains its maximum about the latter end of the first week; that is, when the eruption, if present, is most marked. It begins to decline a few days before the pulse does, and falls rapidly during the last week—a sudden diminution of two or more degrees occurring on certain days. After the subsidence of the fever, the temperature is a degree or two below that of health; and subsequently it rises to be a degree or two higher than the normal tem- perature. Generally it reaches its minimum earlier than the pulse, in the same way as it begins to rise and reaches its maximum earlier. The earlier the pulse and temperature begin to fall, the earlier the fever may be expected to subside. Dr. Parkes has shown that the amount of urea excreted has a certain correspondence to the temperature; that a sudden diminution of the temperature is coincident with the occurrence of a " critical discharge; " and that a diminished excretion with a per- sistent high temperature is fraught with danger, indicating the proba- bility of the approach of inflammatory complications. It is further to be observed that in typhus the general height of the range of tempera- ture does not appear to be proportionate to the duration or severity of the attack. darker afterwards, and in Case CCXXX. it is noted they are of mulberry color on the arms therefore they must have presented the ordinary character of a typhus rash. All I can say is, that to me thev were in no way distinctive. The absence of eruption in the three typhoid cases (CCXIX., CCXX., and CCXXL), is thus explained by the reviewer —"As the rose spots only appear in 85 per cept. it is not impossible that thev mi»ht have been absent in these three consecutively, and may have been present in the next fifteen " But if so, how is our diagnosis to be assisted by a supposed pe- culiar form of eruption which need not occur in all the cases of the disease admitted into the clinical wards for perhaps six months. 934 DISEASES OF THE BLOOD. Morbid Anatomy of the Edinburgh Epidemic Fever during the Winter Session 1847-48, when Typhoid Disease was prevalent. During this epidemic, I opened the bodies of sixty-three indi- viduals who had died of typhus and typhoid fever, with the following results:— Spleen.—The organ most frequently affected was the spleen. In the majority of cases it was more or less enlarged and softened, presenting a mahogany-brown color and creamy consistence; so that, when pressed, the whole of its parenchyma eould be squeezed out of its capsule. In ten cases the spleen contained yellow fawn-colored discolorations with abrupt margins, sometimes diffused in masses varying in size from a walnut to that of a hen's egg, at others, disseminated in miliary spots through the organ. In two cases* these altered masses of the spleen's substance had softened and burst into the peritoneum, causing fatal peritonitis. In another case, a distinct line of separation was observed to be forming round a mass about the size of a walnut. On examining this altered texture in the spleen with a power of 350 diameters linear it was found to consist of—1st, numerous molecules and granules; 2d, free nuclei; 3d, compound granular cells of various sizes ; 4th, fragments of the fibrous tissue and fusi- form corpuscles of the organ. The granular ft.ftft© ce^s were frequently ruptured, more or less ' '':'$(£' broken down, and appeared to me at that time ftJ&Kft;». to constitute the structural character of a new ^* rivW f°rmati°n which had been described by Roki- (?)' %'r tanski and other German pathologists, as ty- phus deposit. This deposition, according to them, bears the same relation to. the constitu- Kg. 525. Fig. 028. tion of the blood in cases of typhus fever, as tubercle and cancer do to the tubercular and cancerous cachexias. Al- though the facts described by Rokitanski and others are quite correct, as well as his description of the structure of this altered tissue which I confirmed in 18-47-48, further observation has convinced me that these alterations are not peculiar to typhus, and do not constitute a distinct form of exudation. They consist, in point of fact, of a peculiar de- generation of the splenic pulp, which follows a greater or less increased growth of the glandular cells, the morbid anatomy of which is displayed in a series of preparations I placed in the University Museum, where they can be studied. Lungs.—The organs most frequently affected after the spleen were the lungs. The most common lesion was bronchitis, the bronchial lining membrane being of a deep mahogany or purple color, more or less infiltrated with serum or exudation. The fine bronchial tubes were frequently filled with a muco-purulent matter, and in a few cases were choked up with a reddish-brown gelatinous substance, more or less fluid—probably a modified form of the exudation described by Fig. 525. Structure of a decolorized mass in the spleen. Fig. 526. The same after the addition of acetic acid. 250 diam. CONTINUED FEVER. 935 Remak, as discovered by him in the sputum. The apices of the lungs were very commonly oedematous, yielding on section a copious grayish frothy fluid. In fifteen cases, the lungs were more or less consolidated by exudation, which seldom presented the characters of normal hepatiza- tion. It was sometimes of a dirty yellow tint, at others of a .brownish chocolate color, existing in masses of irregular outline, and of variable size, resembling the discolored portions of the splenic pulp, formerly alluded to. In three cases there was pulmonary apoplexy. The dirty yellow or chocolate-colored exudation into the lungs was ascertained, on microscopic examination, to consist of—1st, nume- rous molecules and granules, filling up the air vesicles, and infiltrated into the areolar tissue; 2d, naked nuclei; 3d, enlarged and isolated epithelial cells, with multiplying nuclei; and 4th, several compound granular corpuscles. This material was also supposed to belong to the Fig. 527. Fig. 528. Fig. 529. so-called typhous deposits, but is more probably in part an altered exuda- tion, dependent on the constitution of the blood, and partly a desquama- tion of the epithelium, with tendency to multiplication of inclosed nuclei. Intestines.—The intestines presented the lesion so well described by Bretonneau, Louis, Cruveilhier, and others (dothinenteritis, typhoid ulcer, etc.), in nineteen cases. It consisted of a peculiar alteration of the round and oval glandular patches of the small intestine, exhibiting in its first stage a flesh-colored mass, raised above the mucous membrane, presenting in the round patches the form of a pimple or a split pea, and in the oval ones an abrupt elevation resembling an inverted dish. In the second stage this mass was more or less softened, especially round the edges, exhibiting a tendency to separate and slough. In the third stage, the slough had separated, leaving an ulcer, with abrupt edges, equal in area to the size of the gland affected, but varying in depth, occasionally passing through the muscular and resting on the peritoneal coat of the intestine. In this latter case, the peritoneum externally often presented a red or violet patch of congested vessels, indicating the ulcer below. The elevated patches were observed occasionally to extend as high as the duodenum, and as low as the rectum. In one case numerous dothinenteritic eleva- tions, about the size and shape of a split pea, extended over all the Fig. 52*7. Appearance of exudation and epithelial cells in the lung in a case of typhoid pneumonia. Fig. 528. Another portion of the same lung, after the addition of acetic acid. Fig. 529. Portions of normal epithelium separated from the air vesicles. 250 diam. 936 DISEASES OF THE BLOOD. ascending and transverse colon. In a few cases the isolated follicles in the large intestine were observed swollen and empty, presenting in their centre a dark blue or black spot. In others, the round and oval patches of the small intestine exhibited a grayish or slate-blue appearance. Per- foration of the intestine from ulceration, causing fatal peritonitis, oc- curred in three cases. Dysentery, with flakes of lymph attached to the mucous surface over the ascending and transverse colon, was associated with intense dothinenteritis in one case. Oval and round cicatrices, exhibiting different stages of the healing process of the intestinal typhous ulcer, were observed in two cases. On examining the matter found in the intestinal glands in the above cases, it was shown to consist of numerous molecules and granules associated with free nuclei and cells of the glandular sacs, which were unusually distended, and filled with cell elements in various stages of development and disintegration. In this respect it closely resembled the altered substance of the spleen formerly described, and indeed appeared to consist of the same glandular lesion. Mesenteric Glands.—In all the cases where the intestinal ulcerations were recent, the mesenteric glands were enlarged, soft and friable, and of a grayish or reddish-purple color. Some of these glands reached the size of a hen's egg. On section, they presented a finely granular surface, of a dirty yellow-grayish or dark fawn color, and their substance was generally soft and friable, but sometimes, in one or more parts of the swollen gland, broken down into a fluid of creamy consistence. On examining this creamy matter, or the fluid squeezed from the gland, with a power of 250 diameters linear, it was found to contain numerous cells, generally spherical, varying in diameter from the l-150th to the l-35th of a millimetre. In some cases numerous nuclei were contained in the cell, occupying three-fourths of its interior, generally about the l-200th of a millimetre in diameter. At other times from one to four of these nuclei were seen scattered within the cell. On the addition of acetic acid the cell-wall was rendered very transparent, whilst the nuclei were unaffected. Many of them were free, and at first looked like altered blood-corpuscles, from which they were at once distinguished by the action of acetic acid. (See Figs. 223 to 225, p. 209.) Blood.—The blood in the great majority of cases, was fluid, and of a dirty brownish color. In those instances, however, where the disease had been protracted, and especially in such as presented well- marked glandular disease, firm coagula were found in the heaTt and large vessels. Other Lesions.—With regard to the other lesions observed in the sixty- three bodies, it may be said that in two there were glossitis, and laryn- gitis with tonsillitis; in one, abscess of the kidney ; and in one, abscess of the posterior mediastinum. The brain did not appear to participate much in the disease. It presented only occasional congestion, with slight effusion into the subarachnoid cavity, or into the lateral ventricles. In seven bodies no lesion whatever could be discovered. Such is a summary of the appearances observed in sixty-three bodies of patients who died of fever during the prevalence of the typhoid form CONTINUED FEVER. 937 of the disease during 1847-48. The proportion of typhoid to typhus cases has considerably increased of late years. Pathology and Etioloyy of Continued Fever. With regard to the nature of typhoid, as of all other forms of fever, we know little; but, from what has been said, it is impossible to avoid seeing that the spleen, mesenteric and intestinal glands, are especially liable to be affected. Now these glands constitute part of an apparatus which, I believe, secretes the blood (see Leucocythemia); and if so, we begin to catch a glimpse, at all events, of the connection between altera- tions of these structures and of the blood in fever. Further researches, however, are required to determine the nature of such connection, as well as how far in this disease the glands operate upon the blood, and the blood upon the glands. The same arguments which apply to the uncertainty of diagnosis may be raised against the general doctrine, that the different forms of fever are dependent upon separate poisons, run a separate course, and are governed by laws as distinct as those which regulate the various kinds of eruptive fever. Without denying the existence of various kinds of continued fever, I am of opinion that this doctrine has not been estab- lished. On the contrary, I believe that internal complications, and the accidental circumstances of season, diet, constitution, and other causes of a like nature, modify fever in particular individuals at different times, and that to these the variations observed are in many cases attributable. Moreover I am satisfied that typhoid and typhus fever may occur to- gether epidemically, run into one another, and be mutually communi- cable. This was very well shown in the Edinburgh epidemic of 1847-48, in which both diseases occurred together at the same time and in the same localities, some individuals coming from the same house affected with typhus, and others with typhoid, the latter having intestinal lesion after death, as proved by dissection. At the same time, there can be no doubt that these different forms of fever may succeed each other just in the same manner that there may be relapses or returns of the same form of fever. Of this the following is a good example: — Case CCXXXIIL*—Typhoid succeededby Typhus Fever. History.—Sarah Hewson, set. 23, unmarried, kitchen-maid—admitted October 23d, 1864. She has always enjoyed good health up to the 17th instant, when after exposure to cold she was seized with febrile symptoms. Being unable to work, she took a dose of salts three days afterwards, but weakness and prostration increasing, came to the Infirmary. Symptoms on Admission.—On admission, skin hot and dry; no eruption; pulse 96, of fair strength ; tongue covered with a brown fur. No appetite ; thirst; no diarrhoea nor abdominal pain; no headache. A saline mixture, and beef-tea and milk for nourishment. Progress of the Case.—October 26th.—Pulse 94, weak. To have § iv of wine daili/. Oct. 21th.—A few rose-colored spots visible on the abdomen. Bowels loose, the stools of a pea-soup character. From this time the case assumed the usual char- acters of typhoid, a marked improvement occurring on the 6th of November, being the * Reported by Messrs. Wm. Johnston and R. Mackelvie, Clinical Clerks. 938 DISEASES OF THE BLOOD. 21st of the disease. The prostration from purging was extreme, and her convalesecce greatly prolonged, notwithstanding the liberal employment of wine and food. Dis- missed December 14th. Re-admitted December 18th, with all the symptoms of typhus fever, except an erup- tion. Face flushed and anxious. Skin hot; temperature 104°, covered with perspira- tion. Pulse 128, weak. Tongue white and furred in centre. No appetite; great thirst; bowels constipated. Headache; great muscular depression; sleep disturbed; no delirium. Respiration, 35 per minute, slight cough, and thick mucous expectora- tion ; urine normal. From this time her case went through the usual course of typhus fever, from which she was convalescent on December 26th (14 days from the rigor), and was dismissed quite well January 23d. It appears that on December 12th, two days before she left the house, she had a severe feeling of cold or rigor, but was much better when she left on the 14th. She remained in her brother-in-law's house, feeling weak and unwell, which symptoms in- creasing she returned to the Infirmary. She says that for fifteen days before leaving the house she was in the habit of waiting upon another woman (Boyd) in the ward, laboring under typhus fever, and frequently sat down by her bedside, and as there was no fever in the brother-in-law's house either before or after her visit, she supposes that the disease was caught in this way. Dr. Murchison endeavors to prove that typhus and relapsing fevers are caused by over-crowding, with deficient ventilation and destitution. Typhoid fever, on the other hand, he considers to be caused by emana- tions from decaying organic matter, or by organic impurities in water, or by both of these causes combined. The arguments he has brought forward in support of this theory merit careful consideration, and were steadily kept in view in the inquiry of 1862-63 and since. The facts, however, which came under my notice in the remarkable epidemic of this city (1847-48), already referred to, cannot, I think, be explained, by any such supposition. Further, in none of the many cases which have entered the Infirmary under my care since the views of Dr. Murchison became known, could I trace any relation between the occurrence of the typhoid fever and exposure to putrid organic matter, although in every instance this point was carefully investigated. In one case only has there been a difference of opinion in the class on the subject; and as it exhibits how easily one may be misled and guided by preconceived views, the facts may be specially referred to. Case CCXXXIV.*—Typhoid Fever—Convalescent on the 21st day. History.—Kenneth Sinclair, ast. 21, unmarried, sailor, native of Caithness—ad- mitted 6th May 1864. The patient's health was good previous to the present attack of fever. About the middle of March (1864) he sailed from Wick to Dantzic, in a schooner laden with pickled herrings in barrels, from the lower of which the brine leaked into the hold, producing an intolerable stench. The sailors were allowed plenty of food. with a fair supply of fresh vegetables; but the forecastle in which they slept, was small and ill-ventilated. The boat made the voyage to Dantzic in twelve days, and remained there three weeks, during which time the patient was kept hard at work on board, but was supplied daily with abundance of fresh meat. The refuse of the town being poured into the harbor of Dantzic produces abominable smells in it. About a week before the vessel left, the patient drank by accident some bad water from a pump, and two days afterwards was seized with diarrhoea, which continued up to his admission—his bowels being opened three times a day on an average. The ship sailed from Dantzic to London, laden with wheat, and arrived in the Thames about the 26th of April. The patient worked during the whole voyage, and besides assisted in cleaning the vessel for two days after her arrival. Feeling exhausted, he then applied to an apothecary for some medicine to check his diarrhoea, but it failing, he lay up for some days; after which, feeling himself getting gradually worse, and having been seized with a * Reported by Mr. J. M. Moore, Clinical Clerk. CONTINUED FEVER. 93S rigor, he left London on the 4th May, in the London and Edinburgh steamer, and arrived in Edinburgh on the 6th. Symptoms on Admission.—Patient is exceedingly weak, and unable to answer questions. Tongue covered with a white creamy fur, red at the tip. Bowels loose; stools of a pea-soup character. Tenderness over the whole of the abdomen. Face flushed; skin hot; decubitus dorsal. Pulse 96, incompressible, and of good volume. This appears to be the 11th day of the fever. Progress of the Case.—From this date to 16th (21st day of fever) the patient's bowels were opened on an average twice a day, and his pulse ranged from 88 to 96. On the 16th, pulse 84, good strength, regular, and bowels open twice. The patient con- tinued to progress slowly but steadily, and was dismissed perfectly well on 27th June. Commentary.—The history of this case is given exactly as it is recorded by the Clinical Clerk, which, though generally correct, conveys the impression that the cause of this man's fever was the bad smells and putrid emanations to which he was exposed. After his convalescence he was repeatedly examined and cross-examined by the class, with a view of determining exactly what were the circumstances which pre- ceded his illness. The following were the facts elicited. He was in good health up to the time he left Wick. A horrible smell did pervade the vessel in consequence of some casks containing pickled herrings leaking into the hold. He was ten days on the voyage out; was two days unloading at Dantzic; was another week in the harbor, during which the vessel lay empty; was three days loading her with wheat, and remained other two days. During these twenty-four days he was in perfect health, and performed all his duties on board the vessel. During the last two days of his stay in Dantzic harbor, on one occasion when ashore, he applied his mouth to a pump in order to drink; but after taking one mouthful he desisted as the water had a bad " rotten " taste. During this period the crew were well supplied with fresh meat and vegetables. The vessel then went to Fairwater, six miles below Dantzic, where she remained a week. Two days after arriving there, diarrhoea came on. He continued his work, however, and continued to do so during the ten days occupied in the voyage to London, although during fifteen day3—that is, ever since the diarrhoea commenced—he had about three loose stools every day. On arriving at London, he went ashore and obtained some medicine from a druggist to check his bowel complaint, but he was now seized with shivering and considerable pros- tration. He therefore determined to come to Edinburgh, and arrived there two days afterwards by one of the General Steam Navigation Company's steamers. This circumstantial account, it seems to me, in no way supports the theory that putrid emanations were the cause of this man's typhoid fever. They were removed with the cargo of herrings, twelve days before the occurrence of diarrhoea, which seemed rather to be occasioned by the bad water he drank. Again, if that diarrhoea had been properly treated and checked at the commencement, would he have had typhoid fever at all, the febrile attack commencing fifteen days after the diarrhoea, with rigor, etc. on his arriving in the Thames ? These questions are important, and' the whole history of this man shows how necessary it is to analyse facts carefully before arriving at conclusions as to the cause of disease, Considering the efiTuvia which pervade cities, harbors, and ships, it TABLE OF TYPHOID AND TYPHUS FEVERS, 1862-63. CO © Cases. CCXXXV. CCXXXVI. CCXXXVII. CCXXXVIII CCXXXIX. CCXL. CCXLI. CCXLII. CCXDIII. CCXLIV. CCXLV. CCXLVI. CCXLVII. CCXLVIII. CCXLIX. COIi. Name. Age. E. Robertson Rob. M'Intyre John Smith Ales. Malcolm James Raoch Ann Kennedy Mt. Brisbane Jane Tladdcn 53 W. Macaulcy Occupation. Wm. Clairhew (Eliz. Krohn June Hancock Isab. M'Crie J. Hamsen Isabella Scott Baker Glass-blower Policeman Clerk Message-boy Charwoman Mill-worker Housekeeper Light Porter Policeman Wife of shoe- maker Mill-worker Residence. Thistle Street Norton Place Portobcllo Hill Tlace Blackfriars Wynd Fountainbridge Portobello Grassmarket Portobello No fixed home Exposure to Contagion. Servant Seaman 19 Servant None None None None None None None None Unhealthy neighbor- hood None Not known Skin Eiuptii In the clinical wards when seized In the infirmary No fixed home Mary Stewart 20 Servant Moray Place Some isolated rose- colored spots on abdomen A few isolated rose- colored spots on abdomen A few isolated rose- colored spots on abdomen A few isolated rose- colored spots on abdomen. Two spots—doubtful None Diffused mulberry eruption Intestinal Symptoms. Head Termination. Sympton" Not known Not known None None None Profuse mulberry eruption over the whole body Several isolated rose- colored spots on abdomen None Mulberry eruption Mulberry eruption None None Some rose-colored Profuse diarrhcea- pea-soup stools Diarrhoea, not pro fuse — pea-soup stools Diarrhcea not great —pea-soup stools Profuse diarrhoea- stools like coffee- grounds or chocolate Much diarrhoea pea-soup stools Persistent constipa- tion Slight diarrhcea- stools like coffee- grounds or choco late Constipation Diarrhcea Diarrhcea Slight diarrhcea Constipation Slight diarrhcea Persistent diarrhcea Slight diarrhcea Marked diarrhcea Present Before admis- sion Absent Violent Absent Absent Present Absent Present Present Absent Absc nt Slight Marked Marked Absent Convalescent 21st day Do. 14th day Do. 11th day Died 12th day Convalescent 21st day Do. 14th day Do. 14th day Complicated with pneumonia. Be- tween the 9th and 21st day of the fever there were 81 stools. Complicated with pneumonia. Se- verely purged by medicines before admission. Was repeatedly purged by drugs be- fore admission. Violent head symptoms continued until death. On sectio the intes- tines were found ulcerated. Marked typhoid. Fever considerable. The rash was profuse, general, mul berry, crescentic, and persistent. Do. 7th day Violent fever. Febricula. Do. between The exact day of commencing con the 17th and I valescence could not be deter 21st day mined. Do. 13th day Marked typhoid, recovering early. Died 5 days On admission was very exhausted. after admis- On sectio, intestines were found sion ulcerated. Convalescent Was seized with fever in the wards 14th day from supposed contagion. Do. 14th day Well-marked typhus. Died 4 days On sectio, meningitis with ulcerations after admis- in small intestine. sion. Convalescent Cerebral and other symptoms of 40th day typhus, with diarrhoea and pro- longation of disease, like typhoid. Do. 14th day Marked case of typhoid, recovering on 14th day. CONTINUED FEVER. 941 must always be easy to attribute disease to some such cause. But when we see how frequently these supposed causes are innocuous, and the extreme uncertainty with which they are even coincident with their presumed consequences, we may well ask, are they in truth causes at all ? In the winter session of 1862-63, I reviewed and carefully re-examined .the whole subject of fever, in consequence of the appearance of Drs. Tweedie and Murchison's important works on this disease.* Thirteen cases were the subject of comment, and they were all taken with great care. As too much space would be occupied by recording them at length, I give the chief facts in a tabular form, together with two other cases admitted under my care in the summer of 1863. In all the cases the fever was well marked, and the points more especially investigated were the residence, exposure to contagion or to putrid emanations, as causes, and the diagnosis, more especially as determined by the integu- mentary, intestinal, and arterial symptoms (see opposite Table). Commentary on the Cases Tabidated.—Of these sixteen cases of fever, ten were typhoid, including Case CCXLIX., the nature of which was long doubtful, but from its prolongation beyond the twenty-first day was at length declared to be typhoid. Five cases were typhus, and one febricula. The residences of these cases were widely diffused, the typhoid cases coming from no place especially distinguished for effluvia or bad drainage. The typhus cases originated in the Grassmarket, Fountainbridge, and the Infirmary itself. Great pains were taken to determine the immediate cause of the disease—whether contagion or ex- posure to noxious effluvia—yet, except in the two cases which occurred in the Infirmary, and which therefore are presumed to be owing to contagion, in none could the fever be traced to either cause. Of the ten typhoid cases, a rose-colored eruption was observed in seven. Of the five typhus cases, a mulberry-colored rubeolar eruption was observed ia four, so marked that the cases were considered at first by the clerks to be those of measles. Profuse and continued diarrhoea was present in five of the ten typhoid cases, was moderate in one, and slight in four. Tha pea-soup stools were well marked in four, while they resembled coffee-grounds or chocolate in one—a fatal case. Among the five typhus cases there was constipation in two, slight diarrhcea in two, and coffee- ground stools in one. Of the ten typhoid cases, head-symptoms, amount- ing to excessive pain or delirium, were present in five and absent in five. One of the former had meningitis. Of the five typhus cases, they were present in three and absent in two. Among the ten typhoid cases were three deaths, in all of whom the bodies were carefully examined, and typhoid ulcerations of the intestines found. Of the remaining seven, four were convalescent about the fourteenth day, and three only on or after the twenty-first day—which is said to be the usual period. Of the five typhus cases, four were convalescent on the fourteenth day, while one was later, although the exact day could not be fixed. All who watched these cases were, I think, satisfied, as must be evident from the above analysis, that the systematic descriptions of those writers who * Lectures on Continued Fevers, by A. Tweedie, M.D., etc.; and Treatise on the Continued Fevers of Great Britain, by C. Murchison, M.D., etc. 1862. 942 DISEASES OF THE BLOOD. seek to draw marked distinctions between the various leading pheno- mena of these fevers, especially as regards modes of origin, eruption, intestinal and cerebral symptoms, and day of termination, so far from being uniform, admit of frequent and striking exceptions. It follows that we should be very cautious in hazarding an early diagnosis, and attaching too much importance to any one of these symptoms in par- ticular. In recent times it has been maintained that the gases originating from decomposing animal and vegetable matters, bad drains, etc., are not only the especial causes of certain specific fevers, but that bad smells are the evidence of the existence of these specific morbid causes. Sanitarians and municipal authorities have succeeded in exciting at the present time a public furore on this subject, and are producing effects which for extravagance and uselessness can only be compared with those resulting from the railway mania which existed some years ago. Gigantic works are being constructed, having for their object, not the utilization of human excreta, but channels by which they may be effec- tually wasted. Millions of pounds are to be thrown away in conveying that matter so necessary for the land and for agricultural purposes into our rivers and seas, under the idea that the smells and emanations arising from it are the source of pestilence, and that it should be removed at any cost. The following considerations may perhaps serve to correct erroneous views on this subject:— 1. Atmospheric air, stronyly impregnated with odor of various kinds, is not necessarily injurious to health.—This is shown—1st, In various parts of the world where odorous flowers are largely cultivated for the manu- facture of perfumes. Strangers, indeed, often complain of headaches in such districts, but anything like epidemic diseases are unknown. 2. At Paris there is an establishment at Montfaucon for converting ordure into a dry mass by simple evaporation. It is then called poudrette, and sold for agricultural purposes. The smell of this place to visitors is at first almost intolerable; but the inhabitants of the neighborhood are uncon- scious of it, and it occasions no disease. 3. The state of the Thames in 1858 was loudly complained of in consequence of its putrid odor, but no disease was caused by it. 4. The Craigentinny meadows, near Edin- burgh, have for 200 years been rendered fertile by causing the drainage of the city to flow over them. The odor is often very bad, but they occasion no unhealthiness. 5. The drains in Naples run down to the sea, having large slits in them opening into the streets, and the beautiful bay is rendered foul, close to the shore, with the drainage of the city. This, combined with the sulphuretted hydrogen given off from the volcanic soil, renders the atmosphere so unpleasant, that the rents of the dwellings, unlike what exists in other cities, augment as the apartments ascend in the stair. The latrines in the public hospitals also exhale the most foetid ammoniacal gases. Notwithstanding, neither in the city nor in the hos- pitals is fever, and especially typhoid fever, so common as in other cities of the same size. 6. Drs. Livingstone and Kirk informed me, that in Africa the smell of the mangrove swamps was often intolerable, but was never productive of disease. CONTINUED FEVER. 943 2. Atmospheric air, productive of the most dangerous epidemics, mag be quite inodorous.—This has been proved in various parts of the world, as in the marshes of Essex and Lincolnshire, the low grounds of Hol- land, the Campagna of Rome, the Delta of the Ganges, the swamps of Louisiana, the Guinea coast, Jamaica, and many other places. It has never been known, that those who catch intermittent, remittent, or con- tinued fevers, on visiting such localities, have connected the morbific causes with peculiar smells. It follows that— 3. There is no necessary connection between smells and deleterious gases.—Some of these have smells, such as sulphuretted hydrogen, whilst others are inodorous, such as carbonic acid gas. Now, it is to be observed, that what makes these and other gases injurious is their being so concentrated as to exclude atmospheric air, or their being pent up in con- fined places, from which they escape in injurious quantity. Hence why workmen going down into pits expire, for the same reason that dogs do in the Grotto del Cano. It has been asserted, however, that smells, though not injurious in themselves, give indications of danger. At a discussion on this subject which took place in the Physiological Section of the Brit- ish Association in September 1864, one chemist maintained that during putrefaction the smell was given off first, and the noxious vapor after- wards ; whilst another declared that the smell was given off last, and was the proof that all danger had ceased. The first likened smell to the tail of the lion, which, when seen, gave evidence that the claws and teeth were not far off; while the second, continuing the simile, declared that a sight of the tail was the best evidence that danger was departing. I do not believe that smells, as smells, are injurious to health, nor are they a nuisance to those who live among them; yet, one of the great difficulties in making the sewerage of towns useful in agriculture has arisen from exaggerated notions as to the danger of smells, and the necessity of deodorisation. 4. Fresh seweraye entering into running streams is not dangerous to health.—This is shown—1st, By the state of the Thames in 1858; 2d, By the condition of the Water of Leith, which has been proved by the statistics of Dr. Littlejohn, officer of health for the city of Edinburgh, to be a more healthy district than others in proportion to its population, and by Dr. Millar to be equal, in point of health and as regards death- rates, to the best parts of the town. He shows from the tables of the Registrar-General for Scotland that the death-rate from fever in the Water of Leith district is 17-62; in the whole city 24-5; and in the Canongate and St. Giles' districts, 29-1. Excluding the streets in the Water of Leith district inhabited by the higher classes, the death-rate is 18-80.* 3d, It is not destructive to the fish, for according to Dr. Elliot cf Carlisle,! the salmon have increased in size and weight since the drainage of that city was conducted into the Eden; while it is shrewdly suspected that the famed whitebait of Greenwich and Blackwall actually owe their existence to the peculiar condition of the neighboring Thames. 5. Typhoid or other Fevers cannot be proved to originate from fcecal fermentation or emanations.—It is true that Dr. Murchison has col- * Speech to the Town Council of Edinburgh, March 29th, 1864. + Statement made to Brit. Association of Social Science, 1863. 944 DISEASES OF THE BLOOD. lected many examples where typhoid epidemics have occurred coinci- dently with the opening of some drain, or with imperfect drainage of a place. But an equal number of facts might easily be produced to show that where drainage has been very bad, no fever has originated, or where fever has occurred and drainage has been perfect. The great epidemic of typhus and typhoid fever in Edinburgh in 1847-48 followed failure in the potato crop. Formerly, when there was little or no drainage in the old town, typhus was the only fever met with, and typhoid was unknown. Now, drainage has been largely introduced, and typhoid has become common. Dr. Murchison endeavors to explain this by sup- posing that water-closets, now largely introduced into the houses, diffuse emanations there in consequence of a bad water supply. If such were the case, fever should increase largely in autumn, when the supply of water is scarce; whereas it is always most prevalent in winter, when the water is abundant. Formerly also typhoid fever was as unknown among those who had water-closets as those who had not. Further, it should be remembered that the men who are employed almost constantly in the great London drains, though so much exposed to their emanations, are not particularly liable to fever. 6. Epidemic fever, and especially typhoid fever, therefore, must origi- nate in other causes, amongst which, besides contagion and infection, may be cited starvation, improper quality of food, bad water—especially from springs arising in the neighborhood of cess-pools or churchyards —overcrowding, bad ventilation, and the numerous ills arising from poverty and dissipation. Dr. W. Budd of Bristol has with great ability supported the doctrine, that the cause is a specific virus, always emanat- ing from the body, which may be conveyed by, but never originates in drains.* For my own part, I believe we have yet to discover the cause producing essential fevers. But while there are so many sources of fallacy, we cannot be too cautious in accepting plausible explanations, or in acting upon them, either in our efforts to cure disease or to im- prove the health of towns. Another question which will be found discussed in systematic works , Fig. 530. ^ i relating to the pathology and mode of propagation of continued fever it. * Papers in the Lancet, from 1856-to 1858. Fig. 530. A clinical ward of the Royal Infirmary in 1817, 60 feet by 24, showing the arrangement of fever beds, and the screen which isolated them. CONTINUED FEVER. 945 important, namely, Whether it be or be not advisable and right to admit fever cases into the general ward of an hospital. My reply is decidedly in the affirmative, being satisfied it is far better in every point of view to dilute the contagious element as much as possible, rather than to concentrate it by providing special wards for typhus cases. Previous to 1825 a few fever cases were treated in each clinical ward of this In- firmary without injury to the other patients, the disposition of the fever beds being represented in shadow in Fig. 530. The space around them was partially isolated by a screen partition seven feet high, with a door at each end. At present the arrangement of fever beds in the clinical wards is represented in Fig. 531. Each bed has 1100 cubic feet of space, and 8-J- feet of head room. There is a window on each side of every fever bed, and a space of six feet between it and the adjoining ones. The result of this system has been most satisfactory, as during the last fifteen years there has been no spread of fever in the wards, except on one occasion, which was traced by Dr. Christison to the rules of the house having been neglected.* Treatment of Continued Fever. The general treatment of continued fever which I have found most useful, and which you have seen practised in this Infirmary, consists, during the stage of excitement, of giving saline antimonials, administer- ing slight laxatives if occasion require them, and ordering the head to be shaved and cold applied. Fluid nutrients, such as milk and beef-tea, are given from the first, and wine and stimulants as soon as the pulse becomes weak. In prolonged cases, the effect of pressure on the skin from decubitus must be carefully guarded against, whilst the different complications which arise will require careful management. Salines and Laxatives.—At an early period of the disease, when the skin is hot, and the pulse rapid and strong, the saline mixture generally ordered is the following:— B. Sol. Tart. Antim. 3 ij; Liq. Ammon. Acet. * Monthly Journal of Medical Science, March 1850. Fig. 531. Clinical ward, No. XI., 1858, 81 feet by 24, showing the present ar- rangement.—(Christison.) 60 946 DISEASES OF THE BLOOD. 3 j; Aqua, 3 vss. M. Fiat mist., a table-spoonful to be taken every four hours. Should a laxative or purgative be required, not otherwise, castor- oil is the one usually employed. Water or thin lemonade may be taken ad libitum. Cold to the Head.—The oppressive headache of fever is greatly alle- viated by cold applications to the head. Indeed, none but those who have experienced it can understand the feeling of relief and grateful sensation of ease which is in this way produced. The best method of applying cold I have found to be as follows:—A wash-hand basin should be placed under the ear on. one side, and the head allowed to fall over the vessel by bending the neck over its edge. Then from a ewer a stream of cold water should be poured gently over the forehead, and so directed that it may be collected in the basin, care being taken not to wet the dress or bed-clothes. It should be continued as loDg as it is agreeable to the patient, and repeated frequently. In hospitals, and more especially in fever wards, this method requires too much attend- ance. You will have observed, indeed, that I seldom order cold to the head, experience having taught me that it is more frequently converted into warmth to the head. For, notwithstanding every injunction to the contrary, all that is done in these cases is to moisten a piece of double rag or lint in cold water, and lay it upon the warm head of the patient. In a few seconds it is converted into a warm and steaming fomentation, and too frequently allowed to remain in this condition for hours. Hence, unless cold can be applied properly (and in large hospitals that can scarcely be expected without procuring a nurse for every two or three patients), it is better not to order it at all. It has occurred to me, how- ever, that a water-pipe might be conveyed round the walls of fever- wards, with a vulcanised india-rubber tube and stop-cock attached, so that with a little contrivance the patients might procure a flow of cold water and regulate it for themselves. I am satisfied that much relief would be in this way obtained. To secure the application of cold efficiently, it is necessary that the head be shaved. In all severe cases this is indispensable. Such prac- tice, however, is often stoutly opposed by the friends of young women, who are unwilling that they should lose a handsome growth of hair. I have occasionally compromised the matter by allowing the long hair to float in cold water, and act by capillary attraction on the scalp, so as to keep up a refreshing feeling of coolness. Reyulation of Diet.—During the early period of fever the patient generally loathes all kinds of food. Care must be taken, however, that nourishment should be introduced in the form of drink, and diluted milk, beef-tea, toast and water, thin panada or similar fluids given with a little toast or biscuit. Should collapse come on, together with stimu- lants, chicken broth, good strong beef-tea, or milk should be administered. The danger from fever is not the result of over, but of under nourish- ment, which, by reducing the strength, leaves the patient less capable of struggling with the subsequent weakness. I have especially noticed, with regard to relapsing fever, that those who have fed well in the in- terval have been less affected by the re-accession. The body is also drained of its saline constituents, whilst such as enter with the food are, CONTINUED FEVER. 947 with it. cut off; hence I have found it useful to add a large amount of common salt to the beef-tea, which also renders it more sapid and agree- able to the patient, and serves to clear away the accumulation of fur and sordes that gather about the mouth. On the other hand, when conva- lescence comes on, we should take care not to indulge the appetite too much. We can never be sufficiently grateful to Dr. Graves, of Dublin, for his able advocacy of the principle to " feed fevers." It is only to be regretted he did not apply it more extensively, and cause inflammations to be fed also. Wine and Stimulants.—When, after being rapid and strong, the pulse falters, becomes soft and. weak, very often without losing its fre- quency, it will become necessary to administer wine or other stimulants. The quantity of wine usually given is from three to six ounces a-day ; but in some cases marked by unusual depression, or when the individual has been previously accustomed to alcoholic drinks, a larger quantity, or instead, from one to four ounces of spirits, may be required. Nothing is more difficult than to lay down rules as to the extent to which stimu- lants ought to be given in certain cases, or as to the period when they should be administered. The pulse, strength of constitution, previous habits of the patients, but above all the type of the prevailing epidemic, must be your chief guides. Nothing, perhaps, is more indicative of ex- perience and practical tact in the treatment of fever than the judicious use of stimulants in this disease, and certainly there is no other method of acquiring the necessary knowledge than that of carefully watching their effects in a large number of patients. Among all the agents at your command, there are none which will enable you to conduct a case of fever to a favorable termination more successfully than stimulants, when properly managed. Indeed, it is easy t# conceive that, in a dis- ease where loss of appetite and abstinence from food constitute essential phenomena, a period must arrive sooner or later when artificial support is absolutely required. You should be careful, however, not to prolong their use more than is necessary. Very singular anecdotes still linger about the clerks' rooms of this Infirmary of instances where whole bottles of whisky were consumed daily by fever patients, and where, notwithstanding their recovery, owing to some mistake in the order- book, the whisky was still supplied, and disappeared with surprising regularity. With regard to the complications of fever, I have nothing further to say, than that they must be treated according to circumstances; always keeping in remembrance that active depleting means are never useful, and seldom fail, by diminishing the vital powers, to augment the collapse and increase the danger. Can we cut short a Continued Fever ?—There can be little doubt that it is of immense importance to cut short the disease, if possible. With- out speaking too positively, I have been induced to believe in this possi- bility, under certain circumstances, by means of emetics. A fortnight after being appointed Physician to the Fever Hospital of this city, in 1844, I experienced lassitude, headache, and that peculiar cold feeling in the back which generally usher in fever. I took an emetic of anti- mony and ipecacuanha, and on the following day was well. Three weeks 948 DISEASES OF THE BLOOD. afterwards, I experienced the same symptoms; but thinking it possible that, after all, the emetic had not really been the cause of their removal, I allowed the disorder to proceed, which terminated in a prolonged relapsing fever, with three distinct relapses. I think I have observed the same thing in other cases; and now, as a rule, whenever called in at the early period of fever, I always order an emetic. This practice, so far as I have observed, never does harm, often good ; and although the point is of course impossible to demonstrate, it has, I think, been successful in checking at the onset many cases of fever. With regard to cutting short continued fever by quinine, as contend- ed for by Dr. Dundas, I regret to say that the trial you have seen made of it has entirely failed. In none of the seven cases (Cases CCXIX., CCXX., CCXXIL, CCXXIIL, CCXXIV., CCXXV, and CCXXVI.) in which it was given, notwithstanding the physiological action of the drug was well marked, did it in any way shorten the disease, or produce on its progress, so far as I could ascertain, any amelioration whatever. On the other hand, it may be argued that in one case (Case CCXXIL) it was injurious, by increasing the cerebral complication. Dr. Christi- son also tried it in one case, and Dr. W. Robertson in eight cases, both with a want of success. Thus, in sixteen cases it has been carefully and energetically tried, with uniform failure in all. Therapeutic Action of Quinine in Fever.—The effects produced by large doses of quinine are worthy of observation. With these I became first familiar in the wards of M. Piorry, in La Pitie Hospital, Paris, during the year 1838. At that time quinine was given in enormous doses, with a view of cutting short intermittents, and diminishing the size of the spleen. In this way I frequently saw 50 grains of quinine or 100 grains of salicinc given in one dose, the administration of which was followed by the same effects you have observed to follow repeated doses of 10 grains in the Royal Infirmary. In both cases the principal phenomena induced are vertigo, dizziness of vision, ringing in the ears, often complete deafness, with confusion of ideas, occasionally coma with contraction of the pupil. At the same time the force and frequency of the heart's contractions are diminished, and the pulse, from being 120, strong and full, was frequently reduced in a few hours to 80 beats, which were soft and even weak. The skin at the same time becomes cool and often moist from slight diaphoresis. This sedative action on the heart is apparently the result of the comatose condition produced by the primary action on the brain, as is proved by the fact that the disappearance of the cerebral induces cessation of the circulatory phenomena. In large doses, therefore, quinine is a narcotic. Its principal action, however, seems to be on the ganglionic system of the nerves (See p. 338), through which it operates on the blood-vessels and blood. Of late years it has been called an anti-periodic, from the specific effects it exercises, not only on intermittents, but on all diseases which exhibit a tendency to return at periodic intervals, as certain cases of epilepsy, neuralgia, and even re- lapsing fever. This property is altogether peculiar, and is distinct from what ought to be understood by febrifuge, unless, indeed, the statements and views of Dr. Dundas should be subsequently confirmed. Quinine is also spoken of as being a tonic when given in small doses. INFANTILE REMITTENT FEVER. 949 This property seems to have been attributed to it on account of its bitter- ness, as well as its remarkable effects in the cure of ague. But whether it increases the appetite, stimulates the digestive organs, or in any other way operates by increasing the tone of the system and improving the nutritive powers, is a circumstance which, though generally adopted as true, admits of strong doubt. If quinine be a narcotic in large doses, it is the only one of that class of remedies which is tonic in small doses. No doubt it is very frequently given to convalescents and weakly persons, who get better under its use, but whether this is owing to the quinine, or would not have occurred equally well without it, is a matter very diffi- cult to determine. Of one thing I am satisfied, namely, that it is far in- ferior in tonic properties to many metallic and other vegetable drugs, and consequently a medicine with such known valuable anti-periodic proper- ties, the supply of which also is yearly diminishing, should not be wasted in endeavoring to produce effects so very doubtful as the tonic virtues which have been ascribed to it. For many years, therefore, I have not given quinine as a tonic, and have yet to meet with a case where it is necessary to administer it in order to increase the strength of the system. INFANTILE REMITTENT FEVER—CAN IT BE SEPA- RATED FROM ACUTE HYDROCEPHALUS? Case CCLI.*—Blanche Scott, set. 3 years, of scrofulous habit—admitted into the clinical ward November lOtb, 1851. Her mother states that she enjoyed good health until a fortnight ago, when she was attacked with severe diarrhcea—the stools being thin, of a dirty green color, offensive odor, and mingled with slimy matter. She became dull and peevish during the day, but restless and uneasy at night, when the skin became hot, and the countenance flushed. The diarrhoea and fever continued eight or ten days, accompanied with loss of appetite and great thirst. During the last four days there has been delirium; loss of consciousness; occasional moaning; uneasy gestures in demand for drink; hands frequently raised to the head, with a slight scream ; constant picking of the nose and angles of the mouth with her fingers; latterly, retching and vomiting, and passage of the urine and faeces in bed. Symptoms on Admission.—On admission she presents the following symptoms: —Unconsciousness of surrounding objects, not recognising even her mother; pupils not contractile to light; slight strabismus of right eye ; frequently puts her hands to the head, which is rolled about uneasily ; continual grinding of the teeth, low moan- ing, and occasional muttering. Tip of tongue, which is all that can be seen, very dry, and of scarlet color; loss of appetite; constant thirst; vomiting; involuntary discharges of faeces and urine; on pressing the abdomen uneasiness evidently experi- enced, and moaning increased. Skin hot and dry; no eruption; a small abscess at the back of the neck, with a sanious discharge. Action of heart feeble and flutter- ing. Pulse 140, small, and occasionally intermittent. Breathing short and hurried ; no rales. The head to be shaved, and a blister to be applied over the scalp. To have | ij of sherry wine. Progress of the Case.—November12th.—The fever increased towards night, and she was very restless. This morning it has abated. Skin now cool; pulse 120, stronger and regular; no strabismus; still unconscious. Pus has formed below the blistered cuticle! Nov. 13th.—Accession of fever last night; the pulse rising to 160, and becoming sharp. This morning consciousness has returned; fever abated; tongue dry, brown, and cracked ; swallows without difficulty; pulse 120. Nov. 15th. —There are still accessions of fever at night, and remissions in the morning. The scalp is swollen and boggy to the touch, and pus oozes from it on making pressure. All movement of the head causes the child to cry. No tenderness of abdomen. Bowels are opened three times daily. Faeces are more consistent, of dull gneen color, and offensive smell. Pulse 110, more full. Three parallel incisions were made * Eeported by Mr. W. M. Calder, Clinical Clerk. 950 DISEASES OF THE BLOOD. through the infiltrated scalp, by which a considerable quantity of pus was evacuated. To take 3 j of cod-liver oil three times a-day. Chicken diet. Continue the wine. From this period she rapidly improved. The remittent fever ceased on the 18th. Extensive sinuses formed in the scalp, covering the occiput and neck, which, however, gradually healed on the application of a sulphate of copper lotion. Slight bronchitis appeared on the 25th. The appetite soon after became very good ; her strength im- proved. The incisions in the scalp had perfectly cicatrised on the 1st of December; on the 11th she was discharged, the abscess in the neck, however, not having quite healed. Commentary.—In this case the fever was of a distinctly remittent type—the accessions being very marked at night, and the remissions very considerable in the morning. It commenced with intestinal, which were followed by cerebral symptoms. Was it a case of gastro-enteritis, or of cerebral meningitis, or, as these disorders are called by some, remittent fever, or acute hydrocephalus ? No doubt these two separate diseases exist; but if you ask me by what symptoms you may distinguish one from the other in children at an early period, I should be at a loss to reply. In the whole range of practical medicine, this must be allowed to constitute a question of the greatest difficulty to decide. Indeed, I am inclined to consider that it cannot be done until the disease is so far advanced as to render the cerebral symptoms unequivocally predominant. In systematic works on the practice of physic you will find the diagnos- tic characters of the two diseases set forth with wonderful order and propriety; but if you depend on these at the bedside, you will, in the majority of cases, be greatly disappointed. Now, if the symptoms observed in the case before us be taken into consideration, it will be seen that they partake of the characters of both diseases. Such I believe to be really the case—the old distinctions between remittent fever and hydrocephalus having no basis on morbid anatomy. The former, however, is connected with irritation in the igestive organs, the latter with cerebral congestion or inflammation. t is clear that these two lesions may be conjoined in different cases in various degrees, and hence the different aspects presented in practice. The so-called remittent fever and acute hydrocephalus of authors, then, cannot be separated, and in most instances are mingled together. The case of Scott was one of this description, commencing with symptoms of intestinal derangement, accompanied by fever of a remittent type, com- plicated at a later period by cerebral congestion of an asthenic charac- ter ; in short, the hydrocephaloid disease of Marshall Hall. The treatment was in accordance with this view of the case, consist- ing of small quantities of wine, good nourishment, blisters to the scalp, and subsequently cod-liver oil. Several of you expressed the opinion that this was a case of hydrocephalus, and a few were inclined to give mercury. As to hydrocephalus, much depends on what is meant by that term. If by it is understood cerebral meningitis, then it was not hydro- cephalus ; but if it means certain cerebral symptoms, independent of any particular lesion, then it was. Such symptoms, however, may arise from exhaustion, as well as from over-excitement, and the one we had to do with was certainly a case of this kind, coming on, as it did, after pro- tracted diarrhoea and fever. As to mercury, I have no hesitation in saying, had we depended on it, as some recommend should be done in similar cases, the patient would INTERMITTENT FEVER. 951 never have recovered. It has been said that mercury is the sheet anchor of the practitioner in hydrocephalus. I have never seen it beneficial in undoubted cases of cerebral meningitis, and the diagnosis in the vast majority of instances is so uncertain as to warrant the suspicion that the recoveries which have taken place were not those of true inflammation. In this little girl, notwithstanding the delirium, the coma, the screams, the tossing the hands towards the head, the strabismus, and the insensible contracted pupil—all of which have been placed among the principal evidences of hydrocephalus, the treatment was brought to a successful conclusion by stimulants and nourishment. I do not tell you that this will always succeed; but whenever such symptoms follow protracted diarrhoea, and are accompanied by remittent fever, I am satisfied you may place more reliance upon such treatment, aided by the powers of nature, than upon the vaunted, but in my opinion hypothetical, powers of mercury. INTERMITTENT FEVER. .Case CCLIL*—Tertian Intermittent cured by Quinine. History.—John Kelly, a laborer—admitted into the clinical ward October 20th, 1851. Had always enjoyed good health until three months ago, when he was attacked with intermittent fever in Lincolnshire, while working at the harvest. At first it assumed the quotidian type, but after three weeks it became tertian, and continued three weeks longer. Then being at Morpeth, there was an interval of a fortnight. On leaving Morpeth he was much exposed to cold and wet; the disease returned, and has continued up to the present time. Progress op the Case.—The day after admission he had a well-marked attack of fever. The cold stage continued fifteen minutes, and the hot and sweating stages three quarters of an hour, followed by languor and depression. He was ordered to take five grains of sulphate of quinine three times a day, and a scruple of the drug two hours before the next expected paroxysm. He had two other attacks on the 24th and 26th, the latter being very slight. On the 28th there was no attack, and the scruple dose was suspended. Discharged cured November 5th. Commentary.—The cause of intermittent fever is tolerably well ascer- tained. It is found in all countries which are low, swampy, and humid, and in localities where the ground is marshy, and presents a moist alluvial soil, especially in the neighborhood of extensive woods. We must not suppose, however, that marshes and a moist alluvial soil are the only causes of intermittent, for in India it sometimes prevails in hilly dis- tricts, at a considerable elevation, and is known by the name of hill-fever. We may therefore conclude with Dr. Fergusson, that the cause of inter- mittent is a condition of the atmosphere occasioned by evaporation from the earth's surface, by solar rays rather than by currents of air. The frequency of the disease during the autumn months is in favor of this theory. The occurrence or absence of intermittent fever in particular dis- tricts, according as the circumstances just alluded to be present or absent —be induced or prevented—is another proof of its correctness. Thus it is not a common affection in Paris, but in 1838 I saw it very frequent in the wards of M. Piorry, at La Pitie Hospital. It arose among the workmen of the St. Germains and Paris Railway, who, at a particular * Eeported by Mr. W. M. Calder, Clinical Clerk. 952 DISEASES OF THE BLOOD. part of the line, which was low and marshy, caught the disease in great numbers. They nearly all came to La Pitie, as M. Piorry cured the disease rapidly by large doses of quinine, and was in consequence cele- brated among them; and thus, whilst numerous cases were always present in that hospital, it was very rare in Paris generally. On the other hand, there are many places in which ague was once common where it is now rare, from the draining of marshes, or local improvements in cities. Thus it was formerly common in London, in the district which surrounds the Tower, but disappeared when the ditch was allowed to become dry. I have also been told that, in Edinburgh, when the valley which now separates the old from the new town was a marsh, ague was frequent. At present it is very rare, and never met with except in individuals who have caught the disease elsewhere and travelled to this city. With regard to the nature of intermittent fever we know nothing, although we infer that the peculiar condition of the atmosphere alluded to causes a peculiar change of the blood, on which the disease essentially depends—but the nature of that change—why it should occasion an in- termittent instead of a continued effect—why it should produce in different people a quotidian, a tertian, or a quartan, etc. etc.,—of all this we are ignorant. I cannot see that its pathology has in any way been advanced by endeavoring to connect it with diseased spleen. No doubt this organ is frequently enlarged in ague, and in chronic cases becomes hypertrophied and indurated. But it is also especially liable to undergo changes of texture in continued fever, as we have already seen, p. 934. Piorry contends that congestive enlargement of the spleen is the primary change, and that the general fever is a result. He has brought forward numerous cases, showing that, in ague, this organ may be demonstrated by percussion to be enlarged, and that recovery is commensurate with its diminution in bulk. He cites one case where an individual was knocked down in the street by the shaft of a carriage, which struck him on the left side over the spleen, and in whom the resulting fever was distinctly intermittent. This may have been a coincidence. Careful observation, however, has satisfied me that there is no uniform relation between the enlargement of the spleen and the intensity of intermittent fever, as M. Piorry supposes. We have seen that in leucocythemia the spleen has been much hypertrophied, and no ague occasioned. On the other hand, without denying that lesions of the spleen are very common in connection with ague, we are unable in the present state of pathology, to determine whether this be a cause or an effect, or to indicate why lesion of this organ should sometimes be connected with an intermittent, at others with a continued fever. • The treatment which experience has proved to be most certain and rapid is that by quinine; and I am satisfied that tolerably large doses are more efficacious than small ones frequently repeated. I usually give five grains three times a day, and a scruple two hours before the occur- rence of the attack, and have never seen a case which resisted this treat- ment. Much larger doses have been given. Thus I have seen Piorry give fifty grains for a dose, with the effect in recent cases of at once cutting it short, and rapidly reducing the engorgement of the spleen; ERUPTIVE FEVERS. 953 but a permanent and quick cure I believe to be equally well effected by the medium dose formerly recommended. Quinine in large doses pro- duces very inconvenient effects, such as cephalalgia, vertigo, tinnitus aurium, deafness, and other symptoms, which, should any cerebral com- plication exist, may render it fatal. During the prevalence of intermit- tent at La Pitie in 1838, a man was treated with large doses of the drug, and the head symptoms attributed to its stimulant action. He died, and on examination acute meningitis was found, with exudation of lymph on the membranes. Some years ago Dr. Douglas Maclagan introduced the sulphate of bebeerine as a substitute for quinine, and at the time I tried it with great success. Of late years, however—whether from change in the mode of preparation or otherwise, I do not know—its good effects have not been so uniform. Salicine is a useful drug in intermittent, and from numerous experiments I saw made with it in the wards of La Pitie in 1838, it may be depended on when given in double the quantity of quinine. In some chronic cases which have resisted quinine, arsenic has been found useful. I have frequently seen in the south-west of England a case cured at once by a scruple of Cayenne pepper suspended in water. Indeed, a vast number of remedies have been found occasionally beneficial in inter- mittent fever, but there are none so uniformly successful as quinine. ERUPTIVE FEVERS. There are certain diseases which, in an arbitrary classification, may be considered as febrile eruptions, or as eruptive fevers. They compre- hend especially scarlatina, erysipelas, variola, and rubeola. Occasionally roseola, herpes, or other cutaneous eruptions may be attended with fever, but they are separated from the others by their non-contagious or non- infectious nature. Plague and glanders, on the other hand, are true eruptive fevers ; and with the others mentioned, obey certain laws, which may be shortly noticed. 1. They may be infectious and contagious. By infection is under- stood the power of being propagated through the inhalation of air tainted by the breath or perspiration of the affected person. By contagion is understood communication of disease by actual contact. 2. The present theory with regard to the cause of these diseases is, that it depends upon a morbid poison, a small quantity of which entering the blood produces in that fluid a peculiar change whichis analogous to that of fermentation. To distinguish this change in animal from what occurs in vegetable fluids, the term zymosis has been introduced by Mr. Farr (from £u//.o'o>, to ferment). 3. Some of these animal poisons, if excluded from the air or care- fully dried, will retain their communicating property for a longer or shorter time. This enables us to preserve matter for artificial inocu- lation. Hence also they have been supposed capable of attaching themselves to fomites—that is, substances of a rough surface or downy texture, such as wool, cotton, wearing apparel, dust, etc. It is on this theory that quarantine regulations are founded, the whole of which, 954 DISEASES OF THE BLOOD. together with the facts, real or supposed, that support them, require a thorough revision. 4. All the animal poisons are distinguished by peculiarities in their mode of incubation and development. Thus a period of latency exists between exposure to the poison and accession of the fever, or first rigor. Ao-ain, the eruption appears at different periods after the fever is declared. Thus— Period of Latency Appears after first Rigor from from Scarlatina,........4 to 8 days...................18 to 24 hours. Erysipelas,.......4 to 1 days ...................24 to 60 hours. Variola..........8 to 14 days...................48 hours. Eubeola,.........1 or 8 days ...................12 hours. 5. All the eruptive fevers, strictly so-called, invariably run a natural course, and cannot be cut short. It follows that— 6. The treatment of febrile eruptions has for its object conducting these cases to a favorable termination. To this end exactly the same general rules are to be followed as I previously gave when speaking of continued fever, and the same indications exist for the use of salines and laxatives, cold to the head, wine and stimulants, and regulation of the diet. These I need not again repeat, and I shall confine my observations at present to the more special treatment of the diseases we have studied in the wards. Scarlatina. Case COLIII.*—Mary Clark, set. 17, servant—admitted 20th December 1851. On the afternoon of the 17th her throat became sore, and in the evening she was attacked with rigors, followed by pain in the head and back, and other febrile symptoms. Last night she first observed a red rash upon her chest and arms; this is of a reddish-brown color, and resembles the ordinary eruption of scarlatina; it disappears upon pressure. Pulse 126 and feeble; fauces, tonsils and back of pharynx red and congested; has great thirst and anorexia; tongue moist, with a white fur in middle, through which the red papillae project; bowel3 costive; urine, sp. gr. 1030, contains no albumen—a deposit takes place, containing epithelial scales and crystals of triple phosphate, ty Tinct. Hyoscyam. §ss; Liq. Ammon. Acet. et Aquce puree aa § iij. M. ^j tertid quaque hora. Dec. 22.—Eash disappeared from arms, but is still visible on the chest; pulse 86, and soft; le33 pain in the throat, although fauces and palate are still congested. Dec. 24.—Convalescent, and she was dismissed on the 27th of December cured. Case CCLTV.f—Isabella Husketh, set. 22, a woman of abandoned character, and addicted to intemperance, was admitted 19th December 1851, in a state of high delirium. It was ascertained that on the 14th she had been seized with rigors, followed by great debility, catarrh, and general febrile symptoms. On the following day an eruption appeared on her skin. On admission she was in a state of violent delirium, and required to be tied down in bed. Her eyes were suffused, and very sensitive to light; pulse 120 ; tongue dry and parched, florid-red at the edges, with the papillae projecting through a white fur in the centre; teeth covered with sordes; great pain in throat, increased on swallowing ; submaxillary glands tender on pres- sure, but not enlarged ; eats nothing, but has great thirst; bowels costive ; skin hot and pungent; arms and chest covered with a bright scarlet exanthematous eruption. Six leeches applied to the throat—saline mixture. Dec. 20.—Delirium continues; pulse 125 ; pain in throat relieved. Vespere.—Delirium greatly increased. Nine leeches applied to temples, and to have a draught of solution of morphia and some wine. Dec. 21.—Slept during night, and is nearly sensible to-day; tongue dry and florid; eruption fading ; considerable sore throat. Blister to be applied to the throat. On the * Eeported by Mr. W. H. Broadbent, Clinical Clerk. f Eeported by Mr. J. L. Brown, Clinical Clerk. SCARLATINA. 955 23d the eruption had quite disappeared. The throat symptoms, however, gradually increased. On the evening of the 26th, the breathing was observed to be very short and hurried, and on the morning of the 27th the patient died. Commentary.—The first case is an instance of mild scarlatina running its ordinary course, and terminating in recovery on the seventh day. The second case is an example of severe scarlatina, occurring in a woman ad- dicted to intemperance, and in whom all the symptoms of typhus fever, associated with sore throat, were present, proving fatal on the thirteenth day. Of all the eruptive fevers, scarlatina is the most rapid in its inva- sion and the most variable in its course. Great watchfulness is therefore demanded on the part of the practitioner, especially when the crisis is to be expected, so that if prostration comes on rapidly, or other untoward symptoms appear, he may be prepared to meet them. Perhaps, also, scarlatina is the most infectious of the eruptive fevers ; so that complete separation of the patient from the other members of a young family is at all times to be insisted on as soon as possible. A chief peculiarity of scarlatina is, that in addition to the general fever and characteristic eruption, the tonsils and mucous membrane of the mouth and pharynx are also apt to be inflamed. This occasions difficulty of deglutition, with soreness of the throat, symptoms which require for relief topical remedies, such as fomentations, astringent and slightly acid gargles, or a linctus, etc. If sloughing or ulceration occur, the application of tjie stronger acids, or the nitrate of silver, is often necessary. The difficulty of deglutition sometimes impedes the intro- duction of food into the stomach, and in this way assists in producing prostration, and prevents the administration of stimulants or medicine. It may also, in severe cases, impede respiration, and assist in producing asphyxia directly. A fatal result, however, when it does occur during the primary attack of scarlatina, is generally dependent on the same causes which induce it in typhus fever—namely, congestion of the brain, as indicated by delirium, passing into coma, and followed by prostration of the vital powers. In addition to the throat complication, there are various others, all of which may require a special treatment. In the vast majority of cases, a general treatment, directed in the first place to subduing the excess of fever, and afterwards to supporting the strength, is indicated. Many efforts have been made by different practitioners to check or modify the intensity of the disease by administering various drugs, or carrying out particular kinds of treatment. Hence, during certain epi- demics, or in its visitations to particular educational institutions, various practitioners have been sanguine enough to believe that their especial mode of practice has been more successful than any other. I do not consider it necessary to direct your attention to the numerous plans which have been thus proposed, because all of them have been only par- tial in their operation, and no one of them has been more successful than another. You must remember that the causes of scarlatina are as mysterious and unknown as are those producing any kind of fever; and that its fatality, like that of fever, is to be traced to constitutional cir- cumstances in individuals, to unhealthy localities, or to the so-called 956 DISEASES OF THE BLOOD. type of the particular epidemic. Nothing, therefore, is more difficult under such circumstances, than to judge whether the non-fatality ob- served at one time, or in a certain establishment, is referable to this or that practice. At all events, I have been unable to satisfy myself that any general rule of empirical or rational practice is to be derived from the contradictory accounts which have from time to time been made public on this subject. Dr. Andrew Wood, who has had great experience as physician to Heriot's Hospital and other educational establishments in this city, recommends the following treatment:—Several common beer bottles containing very hot water, are placed in long worsted stockings, or long narrow flannel bags, wrung out of water as hot as can be borne. These are to be laid alongside the patient, but not in contact with the skin. One on each side, and one between the legs, will generally be sufficient; but more may be used if deemed necessary. The patient is to lie be- tween blankets during the application of the bottles and for several hours afterwards. In the course of from ten minutes to half an hour, the patient is thrown into a most profuse perspiration, when the stock- ings may be removed. In mild cases, the effect is easily kept up by means of draughts of cold water, and if necessary, by the use of two- drachm doses of Sp. Mindereri every two hours. In severe cases, where the pulse is very rapid—the beats running into each other—where the eruption is either absent or only partial, or of a dusky purplish hue— where the surface is cold—where there is sickness or tendency to diarrhoea —where the throat is aphthous or ulcerated, and the cervical glands swollen, then he follows up the use of the vapor-bath by four or five grain doses of carbonate of ammonia, repeated every three or four hours. Should this be vomited, then brandy may be given in doses proportioned to the age of the patients. Carbonate of ammonia he considers to act beneficially : 1st, by supporting the powers of life ; 2d, by assisting the development of the eruption; and 3d, by acting on the skin and kidneys. Where the vapor-bath was used early in the disease, and its use con- tinued daily, or even twice or thrice a day, according to circumstances, he has found that the chance of severe sore throat was greatly obviated. In regard to supervening dropsy, he considers that, by the use of the vapor-bath, with the other necessary precautions as to exposure, diet, etc., its recurrence is rendered much more rare. In the treatment of the dropsical cases, it was also very useful, and in some instances might be trusted to entirely. Dr. Wood also condemns all depleting treat- ment, and even purgatives, during the first ten days, thinking them not only not required, but positively dangerous, as tending to interfere with the development of the eruption. In the later stages, as well as in the dropsy, however, he thinks purgatives are often beneficial. Shortly after this treatment was proposed at a meeting of the Medico-Chirurgical Society of this city, I tried it in the following case :— Case CCLV.—Margaret Walsh, aet. 18—admitted 2d July 1852. She is a servant girl, and had always enjoyed good health until June 29th, when she experienced dis- * Eeported by Mr. J. B. Williams, Clinical Clerk. SCARLATINA. 957 tinct rigors, followed by sore throat and febrile symptoms. She admits having called previously on a family in which the disease existed. On the evening of the 30th a bright red rash appeared on the skin, and has continued ever since. On admission, the scarlatinal eruption is well characterised on the chest and arms. The skin is hot; pulse full, hard, and 132 in the minute. Tongue furred, with elongated red papillae projecting through the white crust; great difficulty in deglutition; sore throat; ton- sils and mucous membrane of pharynx swollen and red. There are also cephalalgia, slight deafness, and restlessness at night. Eespiratory functions normal; urine healthy; catamenia regular. She was ordered by the resident clerk eight leeches to the head, a saline antimonial mixture, and eight grains of Dover's powder. On first seeing her the following day, 3d July, I found her in much the same condition as is described in the previous report; the skin still being hot and dry, and the eruption very vivid on the chest and arm3. Hot bottles were ordered to be applied, encased in worsted stock- ings wrung out of hot water, as recommended by Dr. Andrew Wood. July 4th.—A shght perspiration followed the use of the vapor-bath last night. To-day the rash has partly disappeared from the arms, but is now present on the legs as well as chest. Pulse 130, small; urine not coagulable. An astringent gargle for the throat—the vapor-bath to be again applied. July 5th.—Profuse perspiration resulted last night from the use of the vapor-bath. To-day the rash has entirely disappeared; but there is great tenderness of the skin and in the joints on motion. July 9th.—Has continued much in the same condition, but to-day the appetite has somewhat returned, and she has eaten a good breakfast. Her joints are swollen, and there is considerable pain on moving them. Desquamation commencing; throat ulcerated, and to be touched with a weak solution of nitric acid; pulse 84, soft; § iv. of wine daily. July 26th.—Since last report has been slowly gaining strength, but is still far from well. The urine has been carefully examined daily, and has never presented coagulability on the addition of heat or nitric acid. To-day a distinct blowing murmur was discovered with the first sound of the heart, loudest at the base, and propagated along the vessels of the neck; pulse 76, of good strength. August 4th.—Went out a Uttle to-day, and in the evening the feet commenced to swell. August 6th.—Swelling of feet increased. To have a sjuill and, digitalis pill three times a day. August 9th.—(Edema of feet continues ; urine healthy. Venesectio ad Iviij. August Uth.—(Edema of feet disappeared. This morning had a rigor. Was ordered an emetic. August 12th.—To-day is feverish, with great thirst and heat of skin; pulse 123, strong. A saline mixture ordered. August nth.—Febrile symptoms continue, with tenderness over epigastrium; and eight leeches were ordered to be applied there. The cardiac dulness is extended. No friction, but a blowing murmur, as formerly noticed, at the base of heart; respiration somewhat embarrassed. August 20th.—Eespiration normal; no tenderness over epigastrium ; pulse 100, regular and soft. The urine all this time has been tested daily, but has never been coagulable. To-day, however, a deposit existed in the urine, and several cists of the tubuli uriniferi may be observed in it with a microscope. September 1th.— Since last report she ha,s been convalescent, and all her symptoms have gradually dis- appeared. The blowing murmur over base of heart is still present, but not so loud, and the increased dulness has disappeared. Dismissed. Commentary.—In this case the disease, instead of being shortened or rendered milder, was unusually prolonged, and was followed by rheuma- tism, dropsy of the inferior extremities, and by pericardial effusion. The febrile symptoms terminated by critical deposition in the urine so late as the fifty-second day. Although admitted June 29, she was not strong enough to be dismissed from the Infirmary until September 7th. This was certainly an unfortunate case to commence the trial of a new treat- ment ; and yet the girl has been always healthy, and there was nothing to indicate at the commencement that the sequelae would be so severe or so prolonged. I persevered with this plan in four or five other cases, but in all of them it failed to bring about speedy resolution. At last I came to the conclusion that the heat, damp, and exposure, which it was difficult to avoid tended, especially in the class of servants and young women who entered the Infirmary, to rheumatism. I then adopted quite an opposite 958 DISEASES OF THE BLOOD. treatment, kept the skin dry and cool, and have had every reason to be satisfied with the result. Several very severe cases which entered the wards during the winter and summer months of 1856-57 were treated in this way with the best results, of which the following are examples:— Case CCLVL*—Thomas Corrigan, ast. 19, a laborer—admitted September 19th, 1856. He first felt sore throat on the evening of the 16th, followed on the 18th by rigors and febrile symptoms. To-day the rash first appeared, and on admission pre- sents a dusky-red color, covering the face, neck, arms, haunches, and thighs. The throat is much swollen externally on both sides. The mouth is with great difficulty opened, when the tonsils are seen greatly enlarged and ulcerated. The back of the tongue is swollen and covered with a thick crust; anteriorly it is red and dry. Pulse 116, full and bounding. Eespirations 27 in the minute. Deglutition difficult. Skin dry and pungently hot. Orine turbid, and of a reddish-brown color, not altered on the addition of heat. Chlorides scanty. Other organs healthy. Warm fomentations to be applied to the throat, and to use the steam inhaler. E Vin. Antim. 3 ss; Aqua Acet. Ammon. §j; Aquce 3" ivss. M. Sumat 3 ss quartd qudque hord. September 20th.—Has been occasionally delirious. Other symptoms the same. To omit fomen- tations, inhalations, and mixture. B. Acid. Sulph. Dil. 3 ij ; Syrupi 1 j; Infus. Rosar. §vij. M. Sumat § ss quartd quaque hord. September 21st.—Delirium has been violent during the night. At present pulse 76, full and strong. Deglutition and respira- tion somewhat easier. E Vin. Colchici 3 ij ; Spirit. Aether. Nit. § iij ; Aqua; fvss. M. Sumat semiunciam quartd qudque hord. September 22d.—Urine to-day clear: chlor- ides more abundant; no albumen. Pulse 60, not so full. Tongue still dry. Eash has disappeared. Sept. 23d.—Urine natural. Desquamation of the skin commencing. Swelling of tonsils and sore throat greatly diminished. From this time he rapidly re- covered, and was dismissed quite well October 9th. Case CCLVIL*—Eliza Campbell, 83t. 24, a married woman, of weak constitution, with two children, the eldest of whom is recovering from scarlatina, was admitted December 19th, 1856. On the 12th she experienced lassitude and general malaise. On the 15th she had rigors, followed by febrile symptoms, and pain in the back. On the morning of the lGth a rash appeared over the breast and other parts of the body. On the 18th her husband observed that her mind was wandering, and next day brought her to the Infirmary. On admission there is a uniform scarlatina eruption over the back, abdomen, and arms. On the legs there are numerous spots of purpura extend- ing up the thighs. Skin hot and dry. Mouth dry. Tongue brown and cracked in the centre. The jaws are separated with difficulty, showing the uvula and fauces of a scarlet color, without swelling of the tonsils. Bowels costive. Pulse 108, small and weak. Is conscious, though rather confused, and very restless. Other organs healthy. Ordered § iij of Sherry wine and | iv of lemon juice, to be taken during the day with strong beef-tea. An injection of warm water to unload the bowels. December 20th.— Violent delirium during the night. At the visit, pulse 160. Head to be shaved and cold applied. December 21st—Had several hours' sleep during the night, and awoke better. Pulse 110. Eruption fading. Urine dark and turbid, with a copious sedi- ment of urates. To have 3 ss of Sp. Aether. Nit. every two hours, and § ij of brandy, in addition to the wine daily. December 22d.—The rash is fainter. Desquamation commencing. Purpuric spots also disappearing. Still dryness of mouth and cracked tongue. Deglutition easy. Continue nutrients and diuretics. From this time she be- came convalescent. On December 24th there were still traces of the eruption in some places, while desquamation was advancing in others. On the 29th the cuticle sepa- rated from the hands entire. She remained weak for some time, and was not strong enough to be dismissed until January 24th, 1857. Commentary.—In the first of these two cases there was violent angina in addition to the severe fever, with delirium, and yet the dis- ease pursued its natural course, crisis occurring on the seventh day, and he rapidly recovered without an untoward symptom. In the second ease, occurring in a woman of a weak habit of body, who had been under-fed, the scarlatina was associated with purpura, violent head symp- * Eeported by Mr. H. M. Maclaurin, Clinical Clerk. SCARLATINA. 959 toms, but no angina. Strong stimulants and nutrients were administer- ed from the first, with diuretics to assist elimination, and ultimately she did well, without any sequelae, although from her previous weak con- dition, convalescence was prolonged. It has frequently been observed that the urine in scarlatina, especi- ally when dropsy supervenes, becomes albuminous. Dr. James W. Begbie, who has with great pains tested the urine in a considerable num- ber of cases, considers its presence almost uniform. Aware of what he has written on this subject, I have tested the urine daily in certain cases without observing it. This non-persistent coagulability of the urine, as well as various deposits which appear in it on critical days, must, when they occur, be considered as an evidence of the excretion of morbid pro- ducts which have circulated in the blood. Hence they are common, not only in scarlatina, but in all inflammatory affections as well as fevers. This point you must have seen me very observant of in watching for the resolution of inflammations and fever at the bed-side (see p. 174). It sometimes happens, however, that the critical discharge is comparatively slight, and that the organic elements are not dissolved so as to constitute fluid albumen. This appears to have occurred in the following case, for whilst morphological evidence of the crisis existed in the urine, in the form of cells and casts, no albumen could be detected by heat and nitric acid. Case CCLVLTL*—Alexander Johnston, set. 14—admitted June 23, 1851. Three days ago he experienced distinct rigors, followed next day by a general scarlatinal eruption. On admission there was restless delirium, and constant moving of the head from side to side on the pillow. He was apparently conscious when spoken to, but could not answer questions; the tongue was protruded wuh difficulty, dry, and of bright red color, studded with florid elevations; deglutition was much impeded; bowels open; pulse 130, weak; urine voided with difficulty, and diminished in quan- tity, sp. grav. 1025—not acted on by heat and nitric acid; skin hot and dry, covered with the bright-red scarlatinal eruption. Ordered salines and slight diuretics. He con- tinued in the same condition, the angina increasing, and the coma alternating with delirium becoming more pronounced until the sixth day. During this period all the urine passed was carefully examined. The amount was diminished (17 oz. per day), but it was free from deposit, and unaffected by heat or nitric acid. E &P- Aether. Nit. 3 iij; Pot. Acet. 3 ij ; Tr. Colchici % ss ; Aquce % iij. Fiat mist. A tea-spoon- ful to be taken every four hours. On the following day all coma and delirium had dis- appeared. He answers questions when put to him; skin cool; eruption faded; pulse 96, weak; passed 30 oz. urine, which is turbid, with small flakes of a membranous character floating in it. On the eighth day the quantity of urine excreted was 50 oz., and it was still more loaded with sediments. On examining the urine with-a microscope, it was seen to contain—1st, membranous flakes, composed of aggregated rounded particles, apparently agglutinated together, and strongly resembling some forms of vegetable tissue; 2d, rounded and irregular masses with spicula; 3d, amorphous molecular masses. (See Fig. 104, p. 104, as observed in this case.) The whole of these elements, on being analysed chemically by Mr. Drummond, were found to consist of urate of ammonia. Next day the urine was only slightly turbid, and on the following one it was perfectly clear. From this time the boy gradually re- covered. Commentary.—This was a very severe case of scarlatina. The angina was intense, occasionally rendering deglutition impossible. There was delirium on the third day, alternating at night with coma, which was often profound. The worst result was apprehended. It occurred to me that the head symptoms, in this as in several cases of * Eeported by Mr. G. Scott, Clinical Clerk. 960 DISEASES OF THE BLOOD. typhus, might probably depend not so much upon inflammation of the brain as upon absorption of and poisoning by urea, an idea that ap- peared supported by the diminished quantity of the renal excretion, as well as its freedom from all deposit. Remembering the alleged virtues of colchicum in increasing the elimination of this excretion, I ordered it, in combination with diuretics, and the result was remarkable; for on the next day not only had the fever diminished, but the urine was increased in amount, and loaded with urates to an extent and in a form I had never previously seen. It may be argued that the fever had ter- minated by a natural crisis on the seventh day; but I cannot help think- ing that in this case nature was assisted by the colchicum and diuretics. I have tried the wet sheet in several cases of scarlatina, but never could satisfy myself that it either shortened the progress of the disease, or mitigated in any way the symptoms of the patient. In the summer of 1864, Mr; Thomas Evans, one of the clinical clerks, was good enough to make a series of careful observations upon the pulse and temperature of the body, before, during, and after the wet sheet was applied in three cases, in all of which the rash was present, the pulse high, and the heat of skin great. They appeared to me favorable cases for the trial. The following; are the results :— Effects of the " Wet Sheet' on Pulse and Temperature (of Axilla) in Three Cases of Scarlatina. The patients were wrapped in a sheet wrung from cold water, which was afterwards surrounded by blankets, etc. The observations were made from 7 to 10 p.m., during June and July 1864. Case CCLIX. Case CCLX. Case CCLXI. Adamson, Morrison, Baxteb, Female, age 19— Female, age 16—copious rash Female, age 19—scanty rash copious rash on on trunk and extremities appeared on legs en 4th trunk and ex- on admission, 5th day; day—convalescent 9th day. tremities on ai- convalescent 10th day. mission, 6th day; convalescent] 0th day. Day of fever.... 6th day 7th day 6th day 7th day 8th day 3d day 5th day 6th day Length of time} sheet was ap- j An hour 45 min. 54 min. 45 min. 30 min. 30 min. 30 min. 30 min. Q e* o p. o p. a p. p. a; r£ a r^H H ^2 H ^2 H n Fl .2 fl a 3 3 Ph H P4 H p-l H Pn R FV| H P-i H (H H ^ H Before appli-} 1 cation of J 138 101° 130 10( 116 102*° 100 ioiAg 100 102° 114 101*/ 100 100*' 83 100*° 5 min. alter- ( - - - - - 102*° - - 92 101J° -1 ~ 92 99£° 73 99*° 10 min........... — — — _ _ 102*° — _ 92 101}° _l _ 92 100° 73 99*° 15 min........... — — — 100° — 102*° — 101*° 921 loir 104 101*° 94 100J° 76 99*° 30 min........... — — — ioo*° 108 102F — loir 96 102° 104 101*° 94 100*° 80 99*" 45 min........... — — — — — 102f" 5 min. after) taking off j 94 99*° 76 98*° 138 101° 102 100*° 96 100° 74 98} — — — 100*° — — — 101*° 92 101*° —'l01° 94 100*° 8U 99*° 138 101*° — ioo*° — 102° — — 96 102" 110 101*° 94 100*° 78 99*° — -100*° 108;102*° — — 96 102*° 112 101}° 94 102}° | 94 loor 78 99T An hour and) half...........\ - 120 100*° - - - - 1 2 hcurs and half — 100*° ERYSIPELAS. 981 It follows from these observations that, as regards the pulse, it was diminished two or three beats after the sheets had been applied half an hour, but that, on taking it off, it became, in another half hour, exactly the same as before it was put on. "With regard to temperature, the immediate effect of the sheet was to produce a diminution of half a deo-ree, but that, after thirty minutes, the former temperature was regained. On taking off the sheet, the temperature sank one degree, but in thirty minutes had again risen to its previous standard; in an hour and a half was half a degree higher ; and in two hours and a half was ao-ain the same as before. Slight diaphoresis occasionally occurred about an hour after taking off the sheet. I frequently interrogated these patients as to whether they experienced any relief from its application, and it was clear that they did not. They were pleased on its w&pioval, and then felt cool and comfortable for a short time, but soon after were as warm as before. In short, the result of this careful trial led me to the impression that the wet sheet in scarlatina was of no benefit whatever. Erysipelas. Case CCLXII.*—Marion Smails, set. 28—admitted January 8th, 1851. She stated that on the morning of the 6 th she was quite well, but that, after being out for some time, she felt a burning pain in her left cheek, and observed a red spot upon it. This redn'e33 gradually extended down towards the neck, and was accompanied with con- siderable swelling. She applied a mustard poultice to her cheek, which relieved the pain somewhat at first, but afterwards caused a great aggravation of it. On admis- sion, besides the local pain, she complained of great thirst and of a bad taste in her mouth. The tongue was moist; bowels regular; pulse 66, full and strong. The cheek was ordered to be fomented with a lotion of lead and opium. January Utn.— Swelling and redness are much less, as is also the pain. January Uth.—Eedness of the skin completely disappeared. Complains only of a slight soreness in the throat. Dismissed cured. Case CCLXin.f—James Maclaren, aet. 59, a porter, of intemperate habits—ad- mitted November 16th, 1851. Eight days ago, was seized with rigors, followed by in- tense febrile symptoms, which prevented sleep. On the 13th he experienced pain m the left side of his nose, accompanied by redness of the integuments, which rapidly spread over the cheek, eye, and brow of the same side. On the following morning the redness appeared on the right cheek, and in the evening had covered the wholes face. On admission there is great thirst; loss of appetite; furred tongue; hot skin; full and burning pulse, 100 in the minute; great headache, with drowsiness; tmghng pain in the face, which is of a deep red color, in some places approaching purple. 1 he blush extends over the forehead and anterior part of the scalp, and pits on pressure Two bulls have broken, and recently formed scabs on the right side of nose Ordered an antimonial saline mixture, and the face to be dusted with flour. November 11th.— Last night there was low muttering delirium, and this morning, vomiting. In the evening" pulse of the same frequency, but more soft. To omit the mixture. November 18th f^Eedness more extended over the scalp, and fresh bullae have appeared on the forehead. Pulse 80, soft; constipation. To have I iy of brandy daily and to take at present half an ounce of castor-oil. November 19^.-To-day much better. Pulse 80fof good strength; swelling of eyes diminished; redness fading; bulk* scabbing. From this time he gradually got well, and was dismissed cured, November 30th. Commentary.—The first of these cases was so mild as, perhaps, to merit the name of erythema. The latter was a very severe one, occurring in a man of intemperate habits, but terminating in convalescence on the twelfth day. In this latter case a study of the symptoms will show we * Eeported by Mr. T. M. Lownds, Clinical Clerk. f Eeported by Mr. A. L. Mackay, Clinical Clerk. 61 962 DISEASES OF THE BLOOD. have again, as in scarlatina, all the phenomena of typhus fever ; and when erysipelas proves fatal, so in like manner it is by coma and subsequent collapse. Erysipelas, however, is opposed to scarlatina, in being the least infectious of the eruptive fevers, in being the least fatal, and in running a much slower course. In many other respects there is a close analogy between them observable in the kind of fever, the sequelse, and critical discharge of coagulable urine. The general indications for treatment are the same. The special treatment is directed by means of topical applica- tions to diminish the local inflammation. For this purpose numerous remedies have been tried—such as dusting the part with flour, lotion of acetate of lead and opium, cerates, oil, etc. etc.—any of which serve the purpose of cooling the surface, rendering it more soft, and diminishing irritation. There can be no doubt that erysipelas is occasionally a fatal disease, from the intensity of the fever, and amount of integument involved. It is generally supposed that, when it attacks the face and scalp, it is more dangerous than when a similar amount of surface in any other part is affected. This opinion does not appear to be founded on very exact observation. Even when the scalp is extensively invaded, death from erysipelas is a rare occurrence. On going round the wards of the Hotel Dieu in May 1851 with M. Louis, I saw several severe cases of erysipe- las of the scalp, which, I was told, were under no treatment whatever— because, as M. Louis informed me, according to his experience, erysipelas of the scalp was never fatal, unless it occurred in individuals of bad con- stitutions, or was associated with some complication. I need not say that without forming any such exclusive opinion as this, it must be very difficult, in a disease that so generally tends to recovery, to judge how far this or that remedy is beneficial. Mr. Hamilton Bell has recommend- ed fifteen to twenty-five drops of the Tr. Ferri Muriatis every second hour, as a most beneficial remedy in erysipelas. But how this medicine is more successful than the spontaneous operation of nature he did not endeavor to demonstrate. Variola. Case CCLXIV.*—Mary Hogan, set. 7, was admitted December 9th, 1851. Never had been vaccinated. Felt slightly indisposed December 4th ; and on the following day complained of severe headache, pain in the back, nausea, loss of appetite, and great thirst. These symptoms continued, and, on the afternoon of the 7th, a bright red blush was observed on the face and chest, gradually spreading over all the body. On the 8th the red blush became covered with numerous minute elevated papulae; and on the 9th when admitted, numerous vesicles could be detected on the face, arms, and legs. Tongue furred, but moist. No dysphagia. Was ordered a purgative of sul- phate of magnesia. December 10th.—The vesicles are numerous and close together on the face, and in some places confluent. Eyelids much swollen and nearly closed. Bowels are open; pulse 140 ; tongue florid. The hair was cut short, and mild mer- curial ointment, thickened with starch, spread over the face. She was also vaccinated. December 13th.—Pustules fully matured and umbilicated over the trunk and'extremi- ties. The mercurial paste forms a thick indurated crust over the face. December loth. Many of the pustules over the body have burst and discharged their contents. No constitutional disturbance. No pain or itching of the face; all swelling of the eye- lids disappeared. December 18th.—Pustules have all burst, except a few on the feet. Was dismissed January 6th, cured. The face scarcely presented any trace of the dis- ease, and afforded a remarkable contrast to those other parts of the skin which had not been covered with the paste. * Eeported by Mr. J. L. Brown, Clinical Clerk. VARIOLA. 963 Case CCLXV.*—Michael Hogan, set. 9, admitted December 10,1851, a brother of the former case, and also never vaccinated. Felt unwell on the 8th, with shivering, pain in the head, and unusual febrile symptoms. On the next day vomited, and then observed an eruption on the skin. On admission, the face, trunk, arms, and legs are spotted with bright papules at considerable distance from each other, and he says the fever has considerably abated. On the 15th the pustules on the face were fully ma- tured, and here and there a few of them were observed to be confluent. On the 18th those on the inferior extremities were in the same condition. Last night he experi- enced again considerable headache, and to-day the pulse is 120, full; the skin hot, and febrile symptoms well developed. 19th.—Headache violent last night, with great restlessness and insomnia; but to-day these symptoms have abated. From this time convalescence commenced, but he recovered slowly, and was not strong enough to go out until January 19th. A few pits existed on the face, where the pustules had been confluent. Commentary.—The general treatment of small-pox is similar to that of the other eruptive fevers. There is a special treatment, however, applicable to it, which deserves some consideration. The Ectrotic Treatment of Variola. Various methods have been proposed for the purpose of arresting the development of the eruption in variola, and preventing the cicatrices which are likely to form. The treatment, called ectrotic (eKTtTpwo-^w, to render abortive), has been practised principally in France. Serres, Bretonneau, and Velpeau, cauterised each vesicle as it appeared with nitrate of silver, which immediately arrests its further progress. This is a very tedious process, while painting the surface with a solution of the caustic causes so much pain and febrile disturbance that it cannot be safely employed. Sir Joseph Oliffe, of Paris, recommended the vigo- plaster of the French Pharmacopoeia; and having seen, in some of the journals, that mercurial ointment, thickened with starch, had proved very serviceable in the practice of M. Briquet and others, in the Paris hospitals, I tried it in numerous cases which were admitted into the wards, and have seen the good effects of the practice. The two cases you have just had an opportunity of observing, however, especially demonstrate this. Case CCLXIV. presented the most confluent form of the disease I ever saw. The entire face was so crowded with the papules and minute vesicles of the incipient stage, that there was literally not room to place a pin'3 head anywhere on the sound skin. It was evident that the whole surface of the face would be one mass of suppuration; and such of you as have had an opportunity of observing a similar case of the disease must be aware of its horrible aspect, the excessive agony produced, the great swelling of the eyelids, the dreadful suppuration and fcetor of the discharge, the violent secondary fever, and the frightful cicatrices with which the countenance is afterwards covered. In this case none of these symptoms were present, and there can be no doubt that the ectrotic treatment really checked the progress of suppuration and modified the disease. From the moment the plaster was applied, all smarting and pain in the face ceased; the eyelids were never swollen; no suppuration occurred; there was no secondary fever; and on the mask leaving the face there was no pitting or suppu- ration. In other parts of the body the eruption passed through its * Eeported by Mr. W. M. Calder, Clinical Clerk. 964 DISEASES OF THE BLOOD. usual stages, and the girl was dismissed from the house well, thirty days after the first commencement of the eruption. Considering this case was likely to be a very severe one, I felt myself authorised to use every means in my power to check the disease; and as it has been asserted that vaccination, even after the commencement of the eruption, modifies its progress, I caused the girl to be vaccinated on first seeing her. At that time the face, as we have seen, v,a? closely covered withpapulse and vesicles; and I do not think that vaccination alone could have produced the remarkable result we have witnessed. I do not mean to deny alto- gether the influence of vaccination in such cases, but I have no hesitation in ascribing the beneficial result almost entirely to the ectrotic treatment. To satisfy yourselves still more, if possible, as to the great advan- tage of this treatment, the case of the boy (Case CCLXV.) may be con- ' trasted with that of the girl (CCLXIV.) who also had never been vacci- nated. His was evidently a very mild case, the eruption discrete, and the constitutional disturbance slight. I allowed it to run its natural course, and the result was in every respect different from that in which the plaster had been applied to the face. The secondary fever was toler- ably smart, the subsequent prostration proportionally severe ; recovery was delayed to the thirty-ninth day, and notwithstanding the generally discrete character of the eruption a few pits existed on the face. Since I first practised this ectrotic treatment in small-pox, I have met with numerous instances in which slight salivation followed the use of the mercurial plaster. Dr. George Paterson,* formerly of Tiverton, however, published a case in which salivation from the em- ployment of the strong mercurial ointment was excessive and danger- ous. I quite agree with that physician in thinking the occasional occurrence of such violent salivation would seriously compromise the otherwise remarkable advantages of the ectrotic treatment. But it may be asked whether, after all, the mercury is in any way necessary to the success of this treatment. Its original propounders in Paris may indeed have supposed that the absorbent powers of the drug constituted the true cause of its success, but it seems to me that another explanation may be offered. There is, for instance, a close analogy between the mode of healing of wounds and ulcers, so well described by Dr. Macartney of Dublin—that is, the so-called " modelling process "— and what takes place in the ectrotic treatment of small-pox. In the former, cicatrices are far less liable to be produced than after healing by the first or second intention, and in the latter the pitting or cicatrisation is prevented. The artificial plaster therefore takes the place of the natural scab or clot of blood, protects the parts below, and enables them to heal slowly but more perfectly than if exposed to the air uncovered and uncompressed by superjacent crusts. If this be the correct theory of the ectrotic treatment, the mercurial might be discarded, and any kind of plaster which would concrete on the face might be expected to produce the same beneficial results. In 1854 I determined to try the effects of such a plaster, and after two or three failures succeeded in procuring one that answers perfectly. The first case I treated with simple lard, thickened with starch and powdered charcoal, but it was so little coherent, that * Monthly Journal, Dec. 1852. VARIOLA. 965 the patient, during the night, rubbed it off on her pillow or with her hands, and on her recovery she was pitted all over. In another case I tried carbonate of magnesia saturated with oil. But this also failed. In a third case, however, common calamine (zinci carbonas), saturated with olive oil (proposed by Mr. Bird, one of the clinical clerks), formed a coherent, tough crust, which remained on the face, and was found to answer well. Numerous cases of natural small-pox have been since treated in this manner, with the result not only of preventing the pitting, but of diminishing the local and general symptoms, exactly in the same manner as I have formerly detailed as being the effect of the mercurial plaster. The following is one of these :— Case CCLXVI.*—Alexander Eoss, aet. 13, never been vaccinated, was seized with shivering on the 7th January, followed by the usual symptoms of fever. Entered the Infirmary on the 9th, when a few papules were observed on the face and arms. On the 12 th the face was thickly covered with vesicles, which from their closeness would certainly have become confluent. The mask of calamine and oil was now applied. The disease ran its usual course, the eruption being confluent on the arms and trunk. Throughout the progress of the case the application of calamine saturated with oil preserved a firm and coherent crust, and was renewed from time to time. The patient experienced no smarting of the face, there was no swelling of the eyehds, no purulent discharge, or local unpleasant symptoms of any kind. The secondary fever was tolerably smart, delirium being present two days. On the 22d the mask came off, leaving a clean smooth surface, free from all trace of pitting. Dismissed quite well on the 26 th. The following formula, after numerous trials, has been found to con- stitute a most efficient plaster :—Carbonate of zinc, 3 parts; oxide of zinc, 1 part, rubbed in a mortar with olive oil to a proper consistence. Dr. Wallace of Greenock, in pursuing this treatment, ascertained that the tincture of iodine, which has been recommended as an ectrotic, is of little use, and was led to employ, as the best application, a solution of gutta percha in chloroform, first used by Dr. Stokes, and recommended by Dr. Graves of Dublin. This answers very well, but caoutchouc, from being more ductile, is still better. The general subject of small-pox opens up to our consideration a multitude of facts, of which we may notice three. 1. There can be very little doubt that of late years small-pox has ao-ain become frequent amongst us, a circumstance which some have attributed to a deterioration of the vaccine lymph. That this cause does operate to a certain extent is very probable; but, for my own part, I have been led to the conclusion, that the terror of the disease which formerly prevailed among the public, has, through the protective dis' covery of Jenner, and the energy with which vaccination was originally pursued, in a great measure declined, and that this is the principal cause. For some time multitudes of the lower orders did not have their children vaccinated, and hence why our hospitals are so frequently encumbered with cases such as those we have just witnessed. The universal feeling that we had no remedy for this but rendering vaccina- tion imperative by penal enactments at length led to the Vaccination Act, of which, as it has only been in operation since last June, it would * Eeported by Mr. Bird, Clinical Clerk. 966 DISEASES OF THE BLOOD. be premature to speak. I am informed, however, by Dr. Husband, who takes charge of the vaccinations of the Koyal Dispensary of this city, that the Act is working well. Each parent, on registering the birth of a child, receives a notice that, unless it be vaccinated before the expiry of six months, a penalty of one pound will be inflicted. This has been found amply sufficient. The people generally admit the propriety of the law, and readily bring their children to submit to the operation. A large increase in the vaccinations has already been established, and the best results may be anticipated. For the mode of vaccination, I must refer you to the account given in systematic works on the practice of medicine. It consists, as you know, of making a puncture just sufficient to penetrate the epidermis of the skin, and to enable the vaccine lymph to be applied to the vascular dermis. For doing this surely and rapidly, the little instrument I now show you, invented by Dr. Graham Weir,* is the best you can employ. It consists of a small handle of ivory, with four needle points projecting from one extremity, and a small curved knife for collecting and sepa- rating the vaccine matter at the other (as shown in the cut). The skin is opened by a crucial scratch with the needle points, which are held verti- cally, and are lightly applied, so as merely to remove the cuticle. The advantages of this instrument over the lancet are said to be that the operation is done more speedily, and that it opposes a larger surface for the absorption of the lymph. The lancet, however, is still pre- ferred in the hands of Fjrr £32 some skilled practi- tioners. In all cases the lymph is more liable to be washed away when too great an effusion of blood has been caused. The method of preserving lymph is a matter of great na- tional importance, and has been much improved by the It consists in employing straight : ! ! : i [ ' i j ! 1 simple b Fig, 533. Fig. 534. invention of Dr. Husband. o d Monthly Journal, 1847-48, p. 69. Fig. 532. Dr. Weir's scarificator for vaccination. Real size. Fig. 533. Dr. Husband's tubes charged with vaccine lymph, and their extremities hermetically sealed—(a), various kinds of tubes ; lymph should not be introduced at an expanded end {b); (c), charged from two cases; (d), charged from three cases. Real size. VARIOLA. 967 glass tubes, from 2| to 3 inches long, and l-28th of an inch in diameter, which, when dipped nearly horizontally into the vaccine matter, permit its entrance by capillary attraction. The two ends of the tube are then closed by simply melting the glass with the flame of a candle or of a gas jet (Fig. 533). When used, the two ends of the tube are broken off, and the lymph blown out on the punctured or scratched arm. Dr. Husband informs me that experience has shown that good lymph may be preserved in this way for two years, even in warm climates, with the cer- tainty of succeeding in 90 per cent, of the cases in which it is used. This failure of one case in 10 may be still further reduced one-half by charg- ing the glasses from two cases instead of one (Fig. 534, c). It may be even charged from three or more cases (Fig. 534, d); and, by blowing each portion out on separate punctures, the chances of failure are still further diminished.* It is admitted that the system now so generally practised at the various stations throughout the country, of vaccinating from arm to arm—when the lymph is quite fresh—admits of very few failures. 2. Sometimes small-pox occurs epidemically in a remarkably benign form. It then presents all the characters described by some authors as varioloid. Occasionally it occurs twice, or becomes what is called re- current ; and it has been known to arise frequently after vaccination. In all these circumstances, when mild, it so resembles chicken-pox as not to be distinguished from it. But more than this, it was observed in the epidemic that prevailed in Edinburgh in 1819 and 1820, that small- pox and chicken-pox existed together frequently in different individuals inhabiting the same room, and sleeping in the same bed. Well-authenti- cated cases occurred of individuals inoculated with small-pox in whom the eruption assumed the appearance of chicken-pox ; and again persons inoculated with chicken-pox had small-pox well characterised. The work of Dr. John Thomson, entitled " An Account of the Varioloid Epidemics in Scotland, 1820," contains many facts of this description, which were well known at the time, and an account of numerous experi- ments carried on in the Castle garrison of this place, which have never been controverted, and which fully establish an essential unity in the nature of the two affections. It is evidently inconsistent to suppose that two distinct contagions should exist at the same time, each of which is protective against the other. Those who admit this doctrine must maintain that, whenever the chicken-pox contagion prevailed, the small- pox contagion was excluded, or the reverse ; or, on the other hand, they must admit that variola is produced by the same contagion that gives rise to chicken-pox. The work of Dr. Thomson furnishes ample proof of the correctness of the latter proposition. Dr. Gregory and others who oppose this opinion do so on the ground of the incubative stage being shorter, the whole disease less prolonged, and the constitutional symptoms being mild. These circumstances, you will observe, only point to difference of degree and intensity, not of kind. Dr. Gregory also alleges that he has seen variola occur after cow-pox, and cow-pox * See Exposition of a Method of Preserving Vaccine Lymph, etc., by William Husband, 12mo, Edinburgh, 1860; and Second Eeport of the Medical Officer of the Privy Council, 1860. 968 DISEASES OF THE BLOOD. after variola, and therefore they cannot be identical. So far, however does this appear to me no argument, that, if possible, it confirms Dr. Thomson's observations. The variola he speaks of occurring after cow- pox is evidently modified small-pox; and cow-pox may, in the majority of cases, be reproduced at pleasure. 3. Dr. Jenner, through life, was of opinion that cow-pox, the grease in horses, swinc-pox, and small-pox, were only modifications of each other. He believed that in giving to man cow-pox, he was in reality giving to him small-pox in its primitive and mildest form. Whether cow-pox or small-pox is the original form has been disputed. It occurs to me as more probable that cattle caught it from man, rather than man from cattle—an opinion confirmed by the experiments of Mr. Ceely of Aylesbury, recorded in the "Transactions of the Provincial Medical and Surgical Association" (vols. viii. and ix.) He showed that, by operating on the mucous surfaces of the animal, the cow readily receives the poison of human small-pox, which the constitution of the animal converts into the vaccine. I need not enter at length into the discussion which has been raised on this subject. Suffice it to say, that the identity of the two diseases appears to me to be established by the following incontro- vertible facts:— 1. The prevalence at the same period of the cow-pox among cattle, and the small-pox among men. 2. The transmission by contagion of the small-pox to cattle, and the consequent development of cow-pox in those animals. 3. The transmission by inoeidation of the small-pox to cattle, and the resulting development of cow-pox in those animals. 4. The transmission by inoculation of the cow-pox to man, and the development thereby of a pustule similar in character to the vaccine pox of the cow. 5. The transmission by inoeidation of the cow-pox to man, and the consequent development of an eruption similar, if not identical with small-pox. All these propositions have been established by numerous facts, which you will find ably stated in the " Beport of the Vaccination Section of the Provincial Medical Association." See also Mr. Simon's Government Report on the " History and Practice of Vaccination, 1857." DIPHTHERIA. Case CCLXVIL*—Diphtheria—Recovery. History.—Isabella Speers, set. 31, married—admitted January 5th, 1865. The patient had scarlatina when a child, and has been somewhat deaf ever since, but other- wise remarkably healthy, till her present illness. On 18th December 1864 she lost a child from "diphtheria," and on the 22d she began herself to complain of pain in the throat, accompanied with difficulty in deglutition. On the 24th, two medical men saw her, and prescribed for her a gargle of dilute Condy's solution—a mixture con- taining chlorate of potash, also Tr. ferri muriatis and brandy, at the same time * Eeported by Mr. W. Johnston, Clinical Clerk. DIPHTHERIA. 969 applying caustic to the throat. About 31st December four dirty white patches appeared on her lower lips, and two small ones under the tongue, which were also treated with caustic; but her throat continuing to get worse, she applied for admis- sion to the Eoyal Infirmary. Symptoms on Admission.—The posterior wall of pharynx and the greater part of both tonsils are covered with patches of yellowish white purulent-looking matter, a little of which, when removed, is found to be very tough, and when subjected to microscopic examination is seen to be composed of pus-cells embedded in mucus. Great difficulty and pain on deglutition. Appetite bad. Headache. Patient is very deaf, and her spirits depressed. Voice reduced to a whisper. Pulse 130, small and weak. Urine copious. No albumen. Other functions normal. Ordered an injection of four ounces of beef-tea and one ounce of wine four times a day. Her throat to be gargled with diluted Condfs liquid, and poultices to be applied externally. Progress of the Case.—January 10th.—The patient's throat looks cleaner, and she expresses herself as feeling on the whole easier. To have some arrow-root with milk and beef-tea, and the injections twice a day. From this time the patient began to mend both in strength and spirits. The nutritive enemata were suspended on the 20th January, as she was then able to swallow a sufficient quantity of food. On the 7th February she was dismissed quite well, except that her voice was still rather husky. Case CCLXVIIL*—Diphtheria complicated with Small-Pox—Death— Diphtheritic membrane covering the Mucous Membrane of the Pharynx, Epiglottis, Larnyx, Tracliea, and Right Bronchus—Pulmonary Apo- plexy. History.—Francis Carroll, aet. 28, married, performer in a circus—admitted No- vember 18th, 1860. Has enjoyed general good health up to the 14th instant, when in the afternoon he felt a sensation of weight in the abdomen succeeded by a restless night. On the following morning he experienced shooting pains in the back and limbs, headache, nausea, loss of appetite, and great thirst. He went to a rehearsal at the circus notwithstanding, when he was seized with shivering and vomiting, and went home to bed. On the following day he took a warm bath, and noticed red spots upon his face, arms, and legs. From the commencement there has been coryza, cough, and expectoration, which on the morning of his admission was tinged with blood. Symptoms on Admission.—The face is swollen, of a dusky red color, dotted over with very closely set elevated purple and red papules, mingled with vesicles and pus- tules the size of small peas, some of which are depressed in the centre. Over the chest, abdomen, groins, and extremities, are livid and dusky red patches, also dotted over with smaller pustules, which are very numerous in the groins. The tongue is foul, the gums spongy, tonsils swollen, fauces and pharynx covered with what appears to be a dirty slough. Complains of sore throat and difficulty of deglutition. No appetite ; great thirst; no nausea or vomiting. Bowels freely open just before ad- mission. Pulse 100, weak. Heart's sounds normal. There is much cough. Is con- stantly spitting a watery frothy fluid, tinged with blood. On percussion there is dulness over the lower third of right lung, posteriorly, where there is crepitation, tubular breathing, and increased vocal resonance. Over the chest generally inspira- tion is harsh, and expiration prolonged. No headache or wandering of mind. Sleep disturbed. Urine high colored and turbid, of natural quantity, coagulable by heat and nitric acid, and deficient in chlorides. E Pot. Acetatis 3 ij ; Sp. Aether. Nit. 3 ij; Mist. Camph. § vss. Ft. Mist. A table-spoonful to be taken three times daily. IJ Sodce Chloruret. § j ; Aquce § xL Ft. gargarisma. To be used frequently. Beef-tea for drink. Wine | iv a day. Progress of the Case.—November 20th.—Tongue brown and dry. Lips and teeth covered with sordes. Has taken nourishment well. Pulse at the visit 74, of good strength. Sibilations heard all over the chest. Pustules on the skin more raised and umbilicated. Throat and other symptoms the same. Has experienced considerable relief from sucking lumps of ice. Urine the same. Face to be smeared frequently with oil. Nov. 21st.—No change. Nov. 22d.—Very restless during the * Eeported by Mr. C. Henry Allfrey, Clinical Clerk, 970 DISEASES OF THE BLOOD. night. Cough incessant. Sputa less abundant but more tenacious, wi.l of dirty red- dish color.. The whole of the mouth and fauces covered with a dirty slough, emitting an offensive odor. Face more swollen, covered with brown crusts from the dried confluent pustules; the intervening skin of a dusky red color, in some places livid. Lips and teeth black from collection of sordes. Can still swallow beef-tea and wine readily. Urine still coagulable. Pulse 100, weak. To have half a teacupful of beef- tea with a dessert-spoonful of wine every half hour. Nov. 23d.—Pulse stronger. Pustules somewhat enlarged, though still very small over trunk and limbs; in many places confluent. Face covered with a uniform brown crust, excoriated below the eye- lids, which are much swollen and closed. Skin generally of a dusky red, in some places livid. Deglutition, though difficult, still performed. Dyspnoea commencing. A table- spoonful of brandy every hour. Continue nutrients. Nov. 24th.—Died at 6 p.m. Sectio Cadaveris.—Forty-two hours after death. The surface of the body presented a copious variolar eruption, consisting of small, flat, imperfectly-filled pustules. The skin of the face was covered with a brownish sanguinolent crust. Throat and Thorax.—The tongue was enveloped with a dirty blackish-brown soft crust. The whole mucous membrane of the velum palati, tonsils, fauces, and pharynx, was covered with a dirty grayish exudation, in some places of a brown tint, which on being scraped off exhibited a mahogany red and softened mucous texture below. The epiglottis was very vascular, and partially coated with the same mem- brane, which extended half down the oesophagus, throughout the larynx and trachea, and could be traced to the end of the large divisions of the right and left bronchi. The right pleurse were united by chronic adhesions. The lower third of right lung posteriorly was infiltrated and indurated with extravasated blood, presenting on sec- tion a smooth, dark purplish-red color. Various other patches of coagulated blood, varying in size from a hazel-nut to a walnut, were scattered throughout both lungs. The bronchi throughout were loaded with a dirty purulent fluid. The heart and peri- cardium were normal. The clots of blood everywhere very soft. Abdomen.—Abdominal organs healthy. Spleen firm. Commentary.—The two cases here recorded are examples, in different degrees, of an affection which, though previously known in most coun- tries under the name of sloughing or putrid sore throat, angina maligna, etc., was first called diphtheritis (Brettoneau), and now diphtheria, from the parchment-like membrane which covers the mucous passages of the fauces and throat (St(pOepi<;).< As it occurs epidemically, is frequently rapid in its progress, appears to be infectious, and causes profound alteration of the system, it is generally considered as a blood disease. On commencing, it is not to be separated from tonsillitis or ordinary sore throat. But when it occurs generally among communities, and espe- cially in schools, its presence, if a sloughing tendency be manifested, may be suspected. In severe cases a dirty gray or tough purulent layer of matter spreads rapidly over the tonsils, uvula, and pharynx, not unfrequently over the internal surface of the mouth, and occasionally of the larynx and trachea. It may or may not be accompanied with fever, but sooner or later causes exhaustion from the difficulty it creates to the re- ception of nourishment. Mr. Wade, of Birmingham, pointed out the very frequent presence of albuminuria as a concomitant. The disease is very rare in the Royal Infirmary, where I have only seen one other case of it in addition to those above reported, in which also it was associated with small-pox. In private practice in Edinburgh, however, it is more common. I have never seen the membrane to contain a fungus such as has been described by some authors, although I am quite familiar with it in the muguet, so common in the infants of foundling hospitals abroad—a disease which bears a close analogy to diphtheria (see Fig. 53). SYPHILIS. 971 With regard to treatment, I Have not found the application of caustic, either solid or in solution, to the diseased part, of any benefit. On the contrary, I think iced water in the incipient stage, and subsequently inhalations of steam, relieve more. Poultices externally, and diuretics internally, when albuminuria is present, are directly indicated (see p. 826). Above all, supporting the strength with nutrients and resto- ratives, so as to gain time and enable the disease to run through its natural progress, is the chief point to be attended to. In case CCLXVII. I believe life was preserved by maintaining the patient for a week on nutritive enemata. Case CCLXVIII. was one of the most frightful I ever witnessed, and its extent, not to speak of the complicated variola and pulmonary disease, stamped it as fatal from the commencement. I have seen diphtheria associated with scarlatina. When the larynx is diseased and respiration affected, laryngotomy should be tried, which, in the prac- tice of Dr. Jenner, of Dr. M'Leod of Glasgow, and others, has saved several lives; otherwise a fatal result may occur in a few days, and is seldom prolonged above a week. On the other hand, diphtheria, with only renal complication, may go on till the fourteenth day. For important information on this subject you may consult the reports of Drs. Green- how and Sanderson, Public Health Reports, 1860; the translation of Trousseau on Diphtheria, by Dr. Semple, and the excellent little mono- graph by Dr. Jenner—" Diphtheria, its Symptoms and Treatment," 1861. SYPHILIS AND MERCURIAL POISONING. Case CCLXIX.*—Syphilitic Ulceration of the Face. Anne Bruce, set. 24—admitted January 10th, 1852. Her face presented a most frightful appearance, being covered, as well as the neck and upper part of the chest, with circular masses of pustular scabs. These varied in size from a fourpenny-piece to half-a-crown, several being in some places crowded together. Some of the prom- inent scabs were dry, others soft, with foetid pus oozing from their bases. In a few places they had fallen off, exposing circular, unhealthy-looking ulcers. Wherever the skin could be seen, it was of a fiery-red color, and puckered with old cicatrices. The lower lip was swollen and dragged downwards, and the left lower eyelid was ulcerated and everted. The metacarpal bones of the left hand were enlarged, and the 3kin covering them red and painful No ulceration of the throat or other com- plaints, with the exception of weakness. External appearance highly cachectic. The history she gave of her case is as follows: About five years ago she con- tracted primary sores from her husband, who had suffered from a very malignant form of them in the West Indies. Shortly after, she was attacked with a minuto pustular eruption of the skin. This shortly disappeared, but was succeeded by occasional blotches on the skin, which sometimes broke, but always went away slowly. Eighteen months after the commencement of the disease, one of these appeared on her chin, when, being alarmed, she came to Edinburgh. The prac- titioner she consulted placed her under a mercurial course, and she was salivated for six weeks. The disease in the face, instead of healing slowly as formerly, now ulcerated and began to spread. Six months afterwards, she was again salivated for four weeks, but the whole of the lower half of the face was now involved, and she entered the clinical ward of the Eoyal Infirmary. She was confident that these arc the only occasions on which she has taken mercury. She remained in the houso upwards of a month, and went out with the face nearly well, from the use of topical emollient applications, and the internal use of small doses of iodide of potassium. Six weeks afterwards, however, she was exposed to cold and wet, when the blotches, scabs, and ulcers returned in the face, and gradually spread to the neck and chest, as formerly described. * Eeported by Mr. G. A. Douglas, Clinical Clerk. 972 DISEASES OF THE BLOOD. She was ordered four grain doses of Iodide of Potassium in a mixture containing § i of tincture of Cardamoms, and § vij of compound infusion of Gentian. The face was dressed first with a zinc lotion, afterwards with one of chloride of lime, and subsequently with an ointment of iodide of lead. Gradually the further ulceration was checked, and the ulcers healed, and on the 19th of February she was so much relieved that she insisted on going out. I saw her in the following June, with the face cicatrised all over, but quite well. Commentary.—It is very rarely that we have an opportunity of seeing so frightful a case of mercurial syphilis as the one just noticed • it fully equalled many of the horrible representations I now show you in the work of Divergie. You will have observed from the history of this patient, that previous to the exhibition of mercury she was subject to the slow formation of boils, which, however, spontaneously disappeared. The moment her system was saturated with that drug the boils and ulcers first became stationary, and then commenced spreading over the integument. This is an important fact too little attended to by those who practise the mercurial treatment. Case CCLXX.*—Syphilitic Laryngitis. Margaret Dickie, a staymaker, aet. 25—admitted September 9th, 1851, laboring under occasional vomiting, frequent cough, with haemoptysis, and copious purulent expectoration. There was considerable sweating at night, and her general health, owing to want of sleep and the harassing cough, was much broken down. At the commencement of the winter session in November I found her taking an acid mixture to relieve the sweating, a cough mixture to diminish the cough, together with cod-liver oil. The chest had also been blistered. Careful percussion and auscultation convinced me that the thoracic physical signs were perfectly normal. I then examined the fauces, which were covered with purulent mucus, but present- ing here and there red and prominent follicles. The cough was also ascertained to be convulsive, the voice hoarse and broken, and, on placing the stethoscope over the larynx, a loud ringing sound accompanied the inspiration. From these facts I had no difficulty in diagnosing laryngitis; and on ascertaining that the woman was a prostitute and addicted to drink, there could be little doubt that it was of syphi- litic origin. The fauces were freely touched with a solution of nitrate of silver (3 ss to f j of water). This was repeated on the following day, and on the next the upper part of the glottis was touched, causing severe convulsive cough. I subsequently passed the sponge, saturated with the solution, into the larynx every second or third day during the month of November, which at first caused very severe and prolonged convulsive cough, that gradually became somewhat diminished. On the whole, however, no great amendment was produced, although the expectoration and cough during the intervals were lessened. The local applications were then suspended, but it soon appeared that they had been beneficial in checking the symptoms, from their severity again increasing, especially the amount of expectoration streaked with blood, and the want of sleep at night owing to the severity of the cough. In the second week of December, therefore, the topical applications were resumed, together with occasional blisters to the larynx, and once more a certain amount of benefit was obtained. But as this treatment, combined with the internal administration of iodide of potassium and bitter infusions, for a period of four weeks, seemed to produce no further improvement, she was dismissed on January 7th, 1852. Commentary.—Syphilitic disease of the larynx is one of the most common of the secondary forms of the disease, a fact indicated by the hoarse and broken voices so frequently noticed among women of abandoned character. The topical treatment with the sponge, and a solution of nitrate of silver, does not seem to be so useful as in simple laryngitis ; but even here its effects on the mucous membrane are evidently beneficial. * Eeported by Mr. C. D. F. Phillips, Clinical Clerk. SYPHILIS. 973 Case CCLXXL*—Syphilitic Rupia, folhiced by Keloid Growths on the Cicatrices—Syphilitic Psoriasis. History.—John Young, aet. 24, boiler-maker, native of New Monkland—admitted November 29, 1858. The patient states that, until eighteen months ago, he was per- fectly healthy, but at that time, while residing at Kilmarnock, he contracted a chancre upon the prepuce. This was treated by the external application of blackwash; and he took what he believes to have been mercurial pills internally. The sore under this treatment healed in a week. He then went to Leith, and after remaining there a fort- night, discovered that an ulcer had spontaneously formed exactly where the previous one had existed. He at this time (July 31st, 1857) entered the surgical wards of the Edinburgh Infirmary, and there took pills which produced soreness of the mouth and gums, and increased salivation lasting for about three weeks. The ulceration of the throat, from which he then also suffered, was frequently cauterized, and black-wash was applied to the preputial sore. Thi3 plan of treatment was followed by a course of iodide of potassium. During his residence in hospital an eruption made its appearance, which was evidently rupia, as proved by the numerous large cicatrices which are at present visible all over the surface of the body. He gradually got much better, and was dismissed after six weeks' residence. At the time of his dismission^ however, there were, according to his own account, numbers of adherent crusts of rupia scattered over the greater part of his body. After he left the Infirmary he went to Motherwell, where his throat again became sore ; fresh pustules of rupia formed, many of the old crusts and sores enlarged, and deafness supervened, which continued for eight or ten days. He applied to a medical man, who syringed his ears with warm milk and water, and gave him some liquid to take internally, which he says benefited him while he continued to use it. Fifteen weeks after this time he went to Cumbernauld, and there purchased a quack's book containing a prescription for sarsparilla and iodide of potassium, whieh he has continued to take from time to time until the present date. The medicine did not cure the disease, but kept it, he believes, from " turning worse." Sis months ago patches of psoriasis commenced to appear on the neck and shoulders, which were soon followed by a similar eruption over other parts of the body. Twelve weelcs ago a medical man made three attempts to inoculate him with syphilitic virus, repeated at intervals of eight days, but without success. The operation was performed by scraping some of the matter off a glass upon which it had been dried, and inserting it under the skin by means of a lancet. Symptoms on Admission.—The entire surface is scattered over with round and oval cicatrices of rupia, which are closest on the thighs, are not so common on the breast and abdomen, but pretty general on the back. In the centre of some of the cicatrices on the upper extremities and back are a few flesh-colored solid elevations, some occupying- only a portion, others the entire surface of these cicatrices* In the latter case they constitute nodular swellings or tumors of a flesh or pinkish color; smooth on the surface and elevated above the level of the skin from one-eighth to one- quarter of an inch; they are indurated and tough to the feel, oval or round in form, and vary from one-eighth of an inch to one inch and a half in diameter. The largest of them is situated over the left shoulder, and about a dozen are scattered over the neck, back, and superior extremities; there are none over the chest, abdomen, or lower extremities. In addition to these there are irregularly-shaped patches of psoriasis scattered over the head, neck, abdomen, arms, legs, and back._ On two of the largest patches irregular ulcers have formed, which are about ha'f an inch in diameter and are at the present time covered with elevated brown crusts. There are numerous small pustules, resembling those of acne, over the shoulders, back, breast, and face, some of which are advancing towards suppuration. Other systems normal. He was ordered to take five grains of the iodide of potassium three times a day, and to apply pitch- ointment to the patches of psoriasis morning and night. Progress op the Case. The treatment just stated was continued for two months. The patches of psoriasis gradually lost their scaly character, and assumed the appearance of copper-colored blotches, and the intervening portions of the skin, owing to occa- sional baths, became much clearer, and freed from the acne. On resuming my duties, May 1st, I found this man still in the house. In the inter- val he had taken Pot. Iodide, Liq. Arsenic, and Liq. Hydrar. Bichl., for various periods internally, and several of the patches and ulcerations had been treated externally with * Eeported by Dr. T. A. Carter, Clinical Physician. 974 DISEASES OF THE BLOOD. nitrate of silver, and solution of cupri sulph. In May he was in no respect better, the patches of psoriasis had now assumed the character of elevated warts of papilloma, of a brownish-red color, and were so evidently chronic that by his own wish he was dismissed May 11th. Commentary.—This case offers a good example of the inutility of mercury, and perhaps even of the evils it produces on the economy, for no one can say how much of the pustular and scaly disease might not have been owing to the effects of that drug. The keloid growths were evidently fibro-vascular tumors, occurring in the cicatrices, and gave him no inconvenience whatever. It is seldom I have seen the skin of a young man so disfigured, presenting, as it did, circular and oval marks of the former rupia, the pink swellings, and the large copper-colored blotches here and there. The literature of syphilis is exceedingly rich. The origin of the word, the source of the disease, the time of its appearance, its subsequent course, and the identity of its different forms at various times, have all been keenly disputed. Even at the present day, its exact nature and mode of treatment excite lively discussion; for such are the discordant facts reported and such are the prejudices resulting from education and ex parte statements, that it is extremely difficult to form an unbiassed, not to speak of a correct opinion. All, then, that I shall venture upon here is to communicate some of my own reflections and observations on this subject. The venereal disease presents a great variety of symptoms, which are generally considered as primary and secondary. They may, with more propriety perhaps, be divided into primary, secondary, and tertiary, as follows •— Primary symptoms— 1. Balanitis. n n i ( Simple or ulcerative. 2. Gonorrhoea,— \ a ± t ■ ' ( Acute or chronic. 3. Chancre. 4. Granular disease of os uteri. ( Testes, Prostate, Rectum, 5. Irritation in other organs,— \ Schneiderian Membrane, ( Conjunctiva, etc. Secondary symptoms, affecting the— 1. Lymphatic glands,—Btibo. 2. Mucous membrane,— Ulcerations. 3. Skin,— Ulcerations or eruptions. 4. Eye,—Iritis, etc. Tertiary Symptoms— 5. Disease of bone,—Exostosis, Caries, Necrosis. The forms of syphilitic disease which commonly fall under our notice, in the medical clinical wards, are such as affect the skin, fauces, and larynx. They all require the same constitutional treatment, but the two latter demand also local applications, some of which have been refer- red to when speaking of laryngitis. SYPHILIS. 975 All the different kinds of skin disease formerly described may occur in an individual affected with syphilis. They then become modified in their general appearance, course, and seats of predilection. Thus it has been observed that the ordinary red color of skin diseases assumes, in those affected with syphilis, a darker or coppery tint. This is especially observed in the scaly eruptions, the patches of which are also smaller, while the scales are thin, and of a gray color, often approaching black. The pustular scabs are hard and thick, of a dark greenish or black color, furrowed on the surface, and deep iu the skin. The ulcers are deep, circular, with hard and callous edges. The cicatrices are unequal, round, or spiral, white and depressed. These eruptions may occur all over the surface, but are most common on the forehead, face, nose, back, and shoulders. In children they generally assume the form of maculae or of ulcerations; in adults, of tubercular and scaly disorders, although ulcers are also very frequent. Diagnosis of Syphilis. It has been said by some persons that they can readily deteeb a syphilitic from all other skin eruptions. But I have known errors made in this respect by the most experienced and eminent dermatolo- gists, one of which I may relate. A young gentleman, on rising one morning, found himself covered with an exanthematous eruption. He had dined out the previous day, and indulged in eating more than usual. He applied to an English physician practising in Paris, who pronounced it to be urticaria, recom- mended a dose of salts, and assured him that it would disappear in a couple of days. Some friends, however, advised him to consult M. Biett, at that time chief physician to the Hopital St. Louis, and certainly one of the most experienced dermatologists in Paris. He did so, and the eruption was stated at once to be syphilitic, and a course of mercury recommended. It was with the utmost difficulty that his English medical adviser could prevail upon him to wait two days before com- mencing the mercurial treatment, when, however, he had the pleasure of seeing his diagnosis justified by the disappearance of the eruption. Now, I need not say, that if such an error could occur to one so expe- rienced as M. Biett, how much more readily may it happen to a practi- tioner comparatively unacquainted with such disorders. The same difficulty occurs with primary and secondary syphilitic ulcers. The question here is, Is there anything in the aspect of the sore itself which will enable us to determine its nature ? Here, also, I have seen the greatest mistakes made by the most experienced surgeons. M. Ricord was so doubtful, after long practice, of the characters of a common chancre, that he commenced a series of inoculations in 1837-38 to determine which was, and which was not, a true venereal sore. So late as 1857 his views on this subject have undergone a complete revo- lution. I am satisfied also, that individuals whose systems have been impregnated with mercury frequently have ulcers which are constantly mistaken for venereal ones, although really the results of a poison with which the body is impregnated. The following case, which I observed 976 DISEASES OP THE BLOOD. twenty-two years ago, was the first which strongly impressed my mind with this truth. A girl, seven years of age entered the surgical hospital in lft36. She had a round ulcer over the tibia, about the middle of the left leg. It presented all the characters of a venereal ulcer, as described by Hun- ter. On inquiry, it appeared that her bowels having been somewhat de- ranged, the mother had gone to a druggist's shop and asked for some opening powders. She received twelve, which contained a white, finely powdered substance. One was given morning and night. In four days profuse salivation came on. The whole dozen powders were given, how- ever, and a cachectic state was induced. Owing to some accident, she received a violent blow on the leg, and the ulcer mentioned made its appearance. There had never been a venereal taint in the family, and the parents were perfectly healthy. The clinical professor declared publicly, that had the girl been seventeen instead of seven years old, no asseverations on her part could have persuaded him that the sore was not syphilitic. Thus, then, it is only when the symptoms arise in a certain order that we can positively declare syphilis to be present. If an individual has chancre, which is followed by bubo or ulcerated throat, and this is accompanied by, or precedes, eruptions on the skin, then we may feel pretty confident. Again, when deep-seated pains in the bones follow the previous symptoms, we may consider them to be syphilitic. The circumstance of an osseous disease more frequently affecting the shaft than the extremities of a long bone will serve to distinguish syphilitic from scrofulous disease and the existence of caries in conjunction with the peculiar ulcerations formerly alluded to, will confirm our suspicions. You should remember, however, that great caution is always required. The common idea that the gonorrhoea and excoriations in men, which often follow impure connection, are a proof of disease in the female, has led to great error; as it is now ascertained that they may occasionally arise from the presence of the menses, some unusually acrid discharge, or other non-venereal cause. A hasty opinion given to the effect tbat this or that eruption is syphilitic has introduced discord into families, and produced incalculable mischief. The tertiary syphilitic symptoms also have frequently been confounded with the deep-seated pains of rheumatism, neuralgia, malacosteon, etc. Moreover, if such opinion leads to the en- tering upon a mercurial course, the original disorder is often replaced by an artificial one, not unfrequently more destructive in character, which is again confounded with syphilis; and so the error is perpetuated. Prcpagation of Syphilis. Actual contact from impure connection is the most common mode by which syphilitic sores are communicated. A gonorrhceal discharge also applied incautiously to the conjunctiva or other mucous membranes will excite inflammation in them. The secondary forms of the disease arc always the result of inoculation; but this may arise not only from the poison being absorbed directly from a primary sore, but may be communi- cated by the mother to the foetus in utero,—by the infant to the nurse, SYPHILIS. 977 —and again by the nurse to the infant. The following case, which was most carefully investigated, and was the subject of legal proceedings, illustrates how nurses may be affected by syphilitic infants. In 1842 the late Dr. W. Campbell brought to me a woman with a child in her arms, to obtain my opinion whether a skin eruption on the latter was or was not syphilitic. I pronounced that it was, and that the woman should cease to nurse it, although her nipples at that time were iu no way affected. The child was the offspring of respectable parents, and had been sent to her to nurse. In consequence of my opinion, the infant was returned to the friends, whose medical attendant maintained the eruption to be non-syphilitic. The woman who applied to me (nurse 1) was received as a wet-nurse into another family, and the child was sent to another nurse (nurse 2). In a week the child died, and a few days afterwards nurse 2 was attacked with sore nipples. Nurse 1, shortly after entering her new situation, also perceived sores round her nipples ; and the medical attendant of the family, after consultation with me, caused her to be discharged. She, in consequence, brought an action against the medical man who had caused the syphilitic infant to be sent to her, and had mistaken the disease. The lawyer she employed then took me to visit nurse 2, whose whole body was covered with a syphilitic tubercular eruption. Both nurses ultimately succeeded in ob- taining compensation from the medical attendant. Pathology of Syphilis. Syphilis is caused by a poisonous virus which, mixing with the blood, taints the constitution, and predisposes it to those forms of secondary and tertiary disorders formerly alluded to. The nature of this virus is involved in the same mystery as that of other animal poisons. All that we know of it is from observation of its effects. Sir A. Crich- ton, adopting Liebig's view of a catalytic action produced in the blood, pointed out, in 1842, that this catalytic action was soon destroyed iu cases of scarlatina, small-pox, and similar acute diseases. Here " the fever, which destroys both the desire for food and the process of chymification, and consequently the supply of new elements for the further formation of new virus, is cut off. But in syphilis and yaws, which do not affect the brain or vital functions for a long time, the patient, by daily taking food in abundance, supplies every day new elements for the production of fresh quantities of poison, and consequently the disease goes on and is protracted indefinitely." This theory is supported by the comparatively mild character of the syphilis in warm climates, where the natives live chiefly on vegetable food, and is abundantly proved by the good effects of a low diet and the most simple means, when contrasted with the effects of so-called specifics. Opinions in the French and German schools have greatly varied in recent times, and at the present moment are most conflicting. Ricord, having nearly all his life supported the views of Hunter, in 1857 an- nounced his adhesion to the view that there were two venereal contagions, —one connected with the seft, and the other with the indurated chancre. The views of Sigmund of Vienna, of Von Baerinsprung of Berlin, of 02 978 DISEASES OF THE BLOOD. Rollet and Diday of Lyons, of Michaelis, and various others, all founded on extensive observation, with numerous inoculations and experiments, are most contradictory. Whether there be one or two poisons is unsettled, and whether they are always distinct or capable of blending and producing mixed sores, equally uncertain. I would refer you to an excellent sum- mary of recent continental opinions by Mr. Hill (British Medical Journal, vol. ii., for 1862). See also the works of H. Lee and Thompson. In the present state of the question too much caution cannot be exercised in forming conclusions regarding it. A few years ago my attention was directed to the skeleton of a dog in the museum of this University, which presented all the aspects of Fig. 535, tertiary syphilis. Its history is as follows :—The dog lived in the shop of Mr. Ballantyne, eighteen years ago, in Carrubber's Close. At that time the work carried on consisted almost exclusively in painting with vermilion and lackering Japan articles. The dog, who never left the premises, was frequently seen lapping the vermilion oil paint, and there can be no doubt that in this way there was introduced into his system a considerable quantity of mercury. After death the dog was dissected. Numerous cancerous-like masses were found in the lungs and internal viscera, and his skeleton was preserved. It will be seen that the shaft of the long bones and not their extremities were attacked (Fig. 535). The disease closely resembles what may be observed in many other specimens of so-called syphilitic disease. (See Figs. 536, 537.) Yet in this dog we have the positive proof that it was caused by mercury, as all attempts to communicate true syphilis to dogs by inocu- lation have failed. For my own part, I believe that the virus of syphilis, if left to itself, Fig. 535. Skeleton of a dog poisoned by mercury. One-fifth real size. SYPHILIS. 979 and if the health of the patient be attended to, will generally wear itself out. Unfortunately we are only commencing to observe the natural pro- gress of syphilis, and consequently we are unable to determine how long, under ordinary circumstances, it takes to accomplish this. So far as I know, we have no specific for any kind of animal poison, for you will remember that Jenner was of opinion (and there can be little doubt that he was correct), that in giving vaccination to man, he was merely giving him small- pox in a modified form. The idea that mercury is a specific for the syphilitic poison, and the incalculable mischief it has occasioned, will constitute a curious episode in the history of medicine at some future day. It is now well known that the poison of mercury produces a cachectic disease and secondary sores on the body, which have been to a great extent mistaken for those of syphilis. It conse- quently has happened that mer- cury given to cure primary sores has produced a constitu- tional disorder closely resem- bling that of syphilis; more mer- Fig. 536. Fig. 537. cury has been administered, increasing the mischief, and so the disease has been perpetuated. The real fact, however, is, that the syphilitic poison is no exception to the general rule, which informs us that all contagious diseases of the blood run a certain course, and that we have not yet dis- covered a specific cure for one of them. The great proof of this is, that the intensity of the disease in modern times has declined exactly in pro- portion as its treatment by mercury has diminished and the disorder been left to follow its natural course. When we treat syphilis on the same principles that we do scarlatina and small-pox, it will prove in- finitely less fatal than those disorders. I have previously referred to the great caution which should be exer- cised in adopting the opinions of some pathologists who ascribe all sorts of chronic indurations, puckerings, gummy exudations, waxy degenera- tions, etc. etc., to syphilis, and call them syphilitic deposits, in the same manner that certain other lesions were formerly called typhous deposits. The general result of such a pathology is to increase the horrors of syphilis, and make it even more dreadful than it was rendered by the imaginative writings of Paracelsus and his followers. I believe these views to be founded in error (see p. 503). Fig. 536. Exostosis of dog's femur. Fig. 537. Internal view. One-half real size. 980 DISEASES OF THE BLOOD. Treatment of Syphilis. The treatment of syphilis may be said to be of two kinds, namely, the simple and mercurial The profession are rapidly deciding in favor of the first, although some of its members still give mercury in inveterate cases. Many of the cases we meet with, therefore, have taken the drug, and we have to eradicate the effects of the mineral poison as well as of the original disease. The Simple Treatment is divided into internal or medical, and external or surgical. The first consists in the observation of certain hygienic rules, and the employment of general therapeutic means. The diet must be light and mild—meat and all stimulating viands retarding the cure ; even with the lightest diet, the hunger should never be quite ap- peased. The regimen must be the more diminished and rigid in propor- tion to the youth and vigor of the patient. Diluent beverages, decoctions of barley, liquorice, and linseed, alone or mixed with milk, should be taken freely, to the amount indeed of several pints a day. Perfect repose must be secured by confinement; to bed. Constipation must be obviated by the use of emollient clysters or mild laxatives. The air should be maintained at the same temperature : this is an indispensable precaution in chronic, consecutive, and mercurial affections. Exercise is only useful in the convalescent stage. In chronic syphilis, however, it may often be carried to fatigue with advantage. Tepid baths, repeated three or four times a day, are always attended with advantage. In the external or surgical treatment, strict attention to cleanliness and the position of the diseased parts should never be lost sight of. Emollient decoctions or fomentations, or dressings of simple cerate, are the best applications, and the dressings should not be too frequently re- newed. The greatest benefit is derived from the external use of a con- centrated solution of opium (in the proportion of about 3 ij to § j of water) ; it soothes excessive irritability in all cases. When the suppura- tion is moderated and the surface of the ulcer cleansed, stimulating dressings, consisting of solutions of the sulphates of alum and copper, the nitrate of silver, and sub-acetate of lead, favor cicatrisation. In inveterate cases, more especially those laboring under tertiary symptoms, the iodide of potassium, which was introduced by Dr. Wallace of Dublin, and used by him with considerable success, may be employed. I have myself given it in numerous cases with benefit, in doses of 5 gr. three times a-day, conjoined with emollient applications to the affected parts. The Mercurial Treatment used to consist in keeping up slight salivation by means of the internal administration of blue pills or some other form of mercury, sometimes conjoined with mercurial frictions or fumigations, at least for the space of a month. More recently much smaller doses, so as to produce scarcely sensible effects have been given for a longer or shorter time. The physiological action of the drug may be produced by administering any of its preparations continuously in small doses. If combined with opium, they act less on the bowels, and more on the sys- tem generally. It is necessary during decided salivation that the patient do not ex- SYPHILIS. 981 pose himself to cold. A certain irritability is produced, and the con- stant soreness of the gums, the metallic taste in the mouth, not to speak of the inconveniences of profuse salivation, which occasionally occurs, render this species of treatment anything but agreeable to the patient. Both kinds of treatment have now been extensively tested. In the year 1822 the Royal Council of Health in Sweden, having been charged by the king to conduct a series of experiments upon the different modes of treating venereal diseases, reports from all the civil and military hos- pitals were ordered to be drawn up annually. These reports establish the inconveniences of the mercurial system, and the superior advantages of the simple treatment. In the various hospitals of Sweden 40,000 cases had been under treatment, one-half by the simple method, the re- maining half by mercury; the proportion of relapses had been, in the first class, seven and a half, in the second thirteen and two-thirds, in one hundred. Dr. Fricke's experiments in the Hamburg general hospital were first made public in 1828. In four years, out of 1649 patients of both sexes, 582 were treated by a mild mercurial course, and 1067 without mercury; the mean duration of the latter method was 51 days, and that by mercury 85. He found that relapses were more frequent, and secondary syphilis more severe, when mercury had been given. When the non-mercurial treatment was followed, they rarely occurred, and were more simple and mild, when met with. He tells us that he has treated more than 5000 patient3 without mercury, and has still to seek cases in which that remedy may be advantageously employed. He has never observed caries, loss of the hair, or pains in the bones following his treatment, and in all cases which have come under his care, much mer- cury had been given. in 1833 the French Consul of Health published the reports sent in by the physicians and surgeons attached to regiments and military hos- pitals in various parts of France. Some of the reports are in favor of a mild mercurial course, others in favor of simple treatment. They all agree in stating the cure by mercury to be one-third longer than by the other treatment. At Strasburg, mercury was only given to very obsti- nate cases. Between 1831 and 1834, 5271 patients had been thus treated, and the number of relapses and secondary affections calling for the employment of mercury was very small. No case of caries, and only one or two instances of exostosis, had been observed. Full reliance may be placed on these facts, as regiments remain in garrison at Strasburg for five or six years. In the various reports now published more than 80,000 cases have been submitted to experiment, by means of which it has been perfectly established that syphilis is cured in a shorter time, and with less pro- bability of inducing secondary syphilis, by the simple than by the mer- curial treatment. These facts are now very generally admitted, and malignant syphilis is gradually disappearing. Thirty years ago the most frightful secon- dary and tertiary cases were met with, and the usual treatment was pro- fuse salivation. At present such cases are rare. Abroad, owing to wise police regulations, the disease is infinitely more innocent than it i3 982 DISEASES OF THE BLOOD. even at present in Scotland; and under the salutary influence of a mild and simple treatment its virulence is daily abating. In appreciating the value of this important revolution in practice, we should not forget to eulogise those who had first the boldness to introduce it. The credit of this is mainly due, in England, to Mr. Fergusson and other British army surgeons, who practised it during the Peninsular campaign (Medico-Chir. Trans., vol. 4)—and to Mr. Rose of the Coldstream Guards (Ibid., vol. 8). In Scotland the writings and lectures of the late Professor John Thomson of this Uni- versity were mainly instrumental in convincing Scotch practitioners of the evils of mercury in venereal diseases. In England the Hunterian theory and practice have been deeply rooted, and in Ireland have been supported by the writings of Carmichael and Collis. Mercury in con- sequence is still very generally employed in those parts of the kingdom. The gigantic experiments made abroad, however, ought to convince the most sceptical—if not, let him compare what syphilis is in Scotland with what it was, and especially observe that we never see an instance of the disease such as those recorded (Cases CCLXIX. to CCLXXL), unless the patient's system has been contaminated with mercury. For an account of the treatment by inoculations, or what is called " syphilisation," in Italy, France, and Norway, which was apparently commenced in Case CCLXXL, I must refer you to papers by Drs. Murchison and Lindsay, in the Edinburgh Monthly Journal for June 1852, p. 575, and November 1857, p. 407. See also the Brit, and For. Medico-Chir. Review, vol. 45, p. 118; and Dr. Boeck's pamphlet, "De la Syphilisation: etat actuel, et statistique "I860. ^ I have en- deavored to impress upon you the great difficulties which exist in forming a correct diagnosis of syphilis. Until this is made more certain nothing can positively be determined with regard to the results of ino- culation as a therapeutic procedure. Again, may not the alleged suc- cess which has attended it be explained by the disease going through its natural progress, syphilisation, according to Dr. Boeck, acting best when neither mercury nor other remedies have been employed ? RHEUMATISM AND GOUT. General Pathology and Treatment. The present theory with regard to these affections is, that they are both connected with an increase of lithic acid in the blood. In rheu- matism, this is dependent on excess of the secondary, and in gout on excess of the primary digestion. In rheumatism, however, there is con- siderable excretion of lactic acid by the skin (Todd), while in gout there is an excess of soda, which, uniting with the lithic acid, produces a com- pound of lithate of soda, that may be detected as such in the blood (Garrod), while sometimes it exudes into the cellular tissue of the skin, constituting tophaceous deposits. In both diseases there is an undue balance between the excess of lithic acid and the power of excretidn—in rheumatism by the skin, and in gout by the kidney. This pathology serves to explain the similitudes and differences existing between the RHEUMATISM AND GOUT. 983 two affections. In both there is a certain constitutional state, dependent on deranged digestion, during which exciting causes occasion local effects. These exciting causes in rheumatism are bad diet, hard work, exposure to cold and wet, and its subjects generally are the poor and laboring population. In gout the causes are good diet, indolence, repletion, or indigestion, and its subjects are for the most part the rich and sedentary. The local manifestations in both are acute wandering pains, with swelling—in rheumatism of the large, and in gout of the small joints, constituting the acute attack in the one, and the so-called regular attack in the other. These are combined with a tendency to various complications of the internal viscera, which are more or less dangerous to life. The general indications of treatment are, in both diseases—(1st), So to regulate the nutritive functions as to ensure a due balance between the amount of matters entering the blood as the result of digestion, primary or secondary, and the amount of matters discharged from the economy by the excretory organs. (2), To conduct the acute attack to a favorable termination, carefully watching the internal viscera, and being prepared to act with vigor should these become affected. Hence the treatment of these diseases resolves itself into what may be called curative and preventive—the first having reference to the acute attack, the second to the means most likely to hinder its return ; the one must be carried out by remedies which act upon the blood and excretory organs, the other by the management of diet and exercise. Although the general pathology above mentioned, which considers rheumatism as a blood disease, may be considered on the whole as cor- rect, we are not yet enabled to explain by it the symptoms of an acute attack of the disease, where, in addition to the constitutional disorder, we have local pain, occasional heat, redness, and swelling, with febrile symptoms. Most practical men have attributed these phenomena to a superinduced inflammation, although it has not been shown that exuda- tion occurs, or that it is followed by the usual results of that condition. Besides, its erratic character is opposed to what we know of the process of true inflammation, and calling it an unhealthy inflammation in no way clears up the mystery. The real pathology of acute rheumatism, therefore, has yet to be determined, and, as a preliminary step, a careful histological examination of the affected tissues is absolutely necessary. So far°as I am aware, this has never yet been attempted, if we except some observations by Hasse on the structure of the bones in rheuma- tism (see Monthly Journal of Medical Science for June 1847). Our treatment of this disease, therefore, is purely empirical, some- times directed against the pain, at others against the supposed inflamma- tion ; now attempting to combat the pathological condition of the blood, then striving to remedy its effects by acting on the excretions, and not unfrequently giving specifics, in the hope that any change in the con- stitution, however produced, may be beneficial. In no disorder, pro- bably, has such a crowd of opposite remedies and plans of treatment been extolled, and yet none of them can be depended on; so that it has been hinted that six weeks' rest is the most useful prescription (Warren). The latest author on rheumatism endeavors to explain the fact by ob- 984 DISEASES OF THE BLOOD. serving that this need not to be wondered at by " those who consider the true nature of the disorder, and the variety of circumstances under which the physician may be called upon to minister to his patient's relief. The bleeding, which in the young, plethoric, and robust, mav be necessary to allay excessive vascular action and cause free secretion may in the weakly induce irritability of the heart, and a consequent attack of cardiac inflammation. The opium, which in one person may prove of the greatest service in promoting free perspiration, and in allaying the general irritability of the system, may in another check the biliary and other secretions, and thus prevent the elimination of the rheumatic poison. The continued use of calomel, and the constant purging, which may be beneficial to one patient by removing large quantities of unhealthy secretions, may unnecessarily exhaust the strength of another, and tend very greatly to impede recovery. And so in regard to every remedy which has been proposed. What is use- ful at one time proves useless, or positively injurious, at another; and the conclusion is forced upon us, that what is wanted ' is far less the discovery of untried methods of treating disease, than of discriminative canons for the proper use of those we possess;'—far less the discovery of any new medicines, than the adaptation of our present remedies to the exigencies of each case " (Fuller on Rheumatism, p. 73). These judicious observations may serve to explain the cause of our failure ; but until we obtain more exact information regarding the special pathology of rheumatism, it is in vain to hope for a rational treatment. Occasionally I have tried the effects of special remedies in this disease, and watched a series of cases, all which were treated in the same manner. Thus I have tried aconite, and believe that alone it is of* little service; colchicum also I have given frequently, and am of opinion that in pure rheumatism it is of no advantage, although in gout it is invaluable. Treatment of Acute Rheumatism by Nitrate of Potash. During the session 1851-52 I made another trial of this kind with the nitrate of potash, a remedy formerly recommended by Dr. Brock- lesby, and which had been given with good effect by M. Gendrin in the wards of La Pitie in Paris, as recorded by Dr. Henry Bennet (Lancet, 1844, vol. i. p. 374). It has more lately been pressed on our atten- tion by Dr. Basham (Medico-Chir. Trans., vol. xxxii.), who tells us that from one to three ounces of the salt, if freely diluted in water, may be taken by the patient in the course of twenty-four hours, without any injurious results, but with the effect of relieving in a marked manner the swelling, heat, and pain in the joints. In the following cases the remedy was tried in much smaller doses, and it appears to me with more than average success. Case CCLXXII.*—Mrs. Anderson, aet. 48, sick nurse—admitted December 3d, 1851. States that previous to the present attack she had always enjoyed pretty good health, with the exception of a liability to a shght cough; had been lately sub- jected to much fatigue in her occupation as a sick nurse, and had been exposed to * Eeported by Mr. William Broadbent, Clinical Clerk. RHEUMATISM AND GOUT. 985 cold from sitting up for several nights in succession in a large room, heated by a fire, and ventilated by keeping the windows open. Having no adequate protection from the cold draught thus caused, she became affected with sore throat, and had pain in the chest. This occurred in the latter part of October last, and from that time up to November 20th she suffered from slight shivering and uneasiness ; transient pain in different parts of the body; nausea and vomiting. About a fortnight before admission, she had a distinct rigor, followed by heat of skin and other febrile symptoms, with very severe pain in the joints especially, much increased by any attempt at motion. The vomiting also continued ; and last week she suffered from pain and palpitation in the cardiac region, and at the same time aa aggravation of her former symptoms. At present she cannot move without suffering excruciating agony, having severe pain apparently in every joint of the body. Heart's sounds, impulse, rhythm, and position normal; pulse about 100, weak. Irregular fits of copious clammy perspiration, of acid smell; no oedema of the joints. Urine scanty, dark-colored, deposits crystals of the triple phosphates, with some mucus. Tongue loaded; anorexia; thirst; occasional vomiting; no tenderness on pressing the epigastrium; bowels confined; pulmonary functions normal. E Muriatis Morphice semigranum ; Pulveris Aromatici grana quinque. M. Ft. pulv. Mittantur tales sex. One to be taken every half hour. December 4th.—She took three of the powders last night, after which she fell asleep; and this morning feels somewhat better; she has also had the bowels emptied by an enema, and is now using a diuretic mix- ture. December 5th.—Pains in limbs much the same; gets no sleep; perspiration still copious ; urine not increased in quantity; vomiting continues ; has been taking diuretics and Dover's powder. December 6th.—Had an exacerbation last night, the pain in the joints and limbs being excruciating. E Potassce Nitratis semiunciam; Aqua; uncias sex. Misce et signetur—a table-spoonful every four hours. December 1th.—Has taken three doses of the medicine; she perspired a good deal during the night; urine not increased in quantity; pain is less severe. December 8th.—Still sweats a good deal; pains much the same as yesterday. Adde misturm Nitratis Potass. 3 j. December 9th.—Pains better; copious perspiration; urine increased in quantity; increase of the nausea and vomiting and of the thirst. December 10th.— Pains nearly gone ; sickness continues ; refuses to use her medicine; pulse 80, weak; much general debility. After this date the pain ceased entirely, and she was shortly afterwards discharged cured. Commentary.—This was a severe case of both general muscular and articular rheumatism, of a fortnight's standing when she entered the house. There was still, however, great pain on the slightest movement, which, during two days, in no way yielded to morphia, diaphoretics, and diuretics. On the exhibition of the nitrate of potash, profuse diaphoresis came on, which was apparently kept up by the medicine, with marked amendment to the rheumatic pains, followed by rapid recovery. The improvement could not be attributed to the occurrence of any critical day in this case; and the night previous to the exhibition of the remedy there had been a marked exacerbation. Every one who saw this case felt persuaded that the good effects were attributable to the nitrate of potash. Case CCLXXIII.*—Jane Irvine, S3t. 17, servant, admitted 19th December 1851. States that seven days ago, whilst engaged at her usual occupation, she was s uldenly seized with severe febrile symptoms, and constant pain in the left ankle, •vhieh was increased by pressure and motion; it was red and tumefied. On the iol!owin<>' day the right ankle became similarly affected, and then in succession the knees, shoulders, wrists, and fingers; the pain still continuing, but modified in severity in the parts first attacked. She had been undergoing treatment by diaphoretics, without, however, having experienced any relief, from them. On admission the pulse is 100, fall and soft. A soft bellows murmur, synchronous with ths radial pulse, accompanies the first sound, heard loudest at the base, and is propa- * Eeported by Mr. J. L. Brown, Clinical Clerk. 986 DISEASES OF THE BLOOD. gated along the course of the large arteries. Cannot sleep from the pain, which is general, and is causing intense suffering. Tongue moist, preternaturally red at the tip and margin; no appetite; thirst, nausea, and vomiting; the bowels are costive; some tenderness on pressure in the epigastrium. Urine high colored, deposits a slight sediment of lithates. Skin moist, from copious perspiration; knees and ankles are swollen and painful on the least pressure. The right wrist, especially near the metacarpal bone of the thumb, is at present the seat of greatest suffering, and is red, painful, and swollen. Ordered to be bled to § xvj, and to have a purgative enema. December 20th.—Is much worse to-day; the pains in the wrist and hands are especially aggravated. Copious perspiration still continues. I£ Potass. Nitratis \ ss; Aqua. | vj. A table-spoonful every four hours. December 21st.—Slept during the night. The sweating is still profuse. Urine in moderate quantity, sp. gr. 1016, deposits lithates. Pulse 90, weak; cardiac murmur very indistinct. The pain is considerably relieved, except in the left lower extremity. December 22d.—Still continues taking the Potass. Nit.; the improvement more marked, and she can allow the limbs to be moved about to-day. December 23d.—She presents quite a cheerful appearance to- day, and is entirely relieved from pain; all the joints can be moved quite freely with- out exciting uneasiness. Pulse 68 ; skin cool; tongue clean; appetite returning; bowels regular; urine natural—some sediment. Cardiac murmur is more distinct to- day.—Convalescence proceeded satisfactorily from this date till January 5th, when she was attacked by typhus fever, from which, however, she ultimately recovered, and was dismissed well. Commentary.—This was also a very severe case of general rheumatism, which was in no degree benefited by diaphoretics, and a large bleeding on the seventh day. On the 8th day she was if anything worse, and then nitrate of potash was given, producing marked relief on the follow- ing day. On the eleventh day of the disease, and third from the exhibition of the salt, the disease was subdued and she became convales- cent. Here, again, the period of improvement cannot be confounded with critical days, and strictly corresponds to the administration of ths remedy. The bleeding may have assisted its effects, but certainly was not followed, as is usually the case, by any evident amelioration. This; girl had an endocardial murmur on admission, which continued during the progress of the case, and I ascertained from the medical practitioner who sent her into the house that she had labored under this before the attack of rheumatism came on. Was this, therefore, an anemic murmur independent of the general disease, or produced by it ? We may ask another question—viz., Are all the endocardial murmurs occurring in conjunction with rheumatism caused by endocarditis, and attributable to the rheumatic diathesis ? These questions demand more careful atten- tion to these murmurs in young women than has, I think, hitherto been paid to them. For my own part, I am satisfied that these anemic murmurs in young girls are very common, and that they have frequently been mis- taken for sounds dependent on endocarditis. As the patient becomes more robust these murmurs disappear, and hence, probably, has arisen the idea of the good effects of mercury when given in such cases. Case CCLXXIV.*—Janet Wright. This woman had been admitted October 22d, 1851, laboring under the usual symptoms of acute rheumatism, and had been undergoing treatment by Dover's powder, diuretics, leeching, etc., up to the 6th December, without any benefit whatever, when on that day she was ordered E Potass. Nitratis 3 iij; Aq. § vj. Misce. A table-spoonful every three hours. December 1th. —Has taken four doses of the medicine, but without any good effect. Took a dose of Dover's powder last night, and elept well; pain in the shoulders very severe, and Eeported by Mr. William Broadbent, Clinical Clerk. RHEUMATISM AND GOUT. 987 also in the knees. December 8th.—Pain still continues. Adde misturce Potass. Ni- tratis 3j. December 10th.—Has been using the medicine regularly; she says it makes her very weak, sleepy, and stupid. She sweats a good deal at night, and the urine is increased in quantity; is very thirsty, and complains of bad taste in her mouth; pains gone from knees. December 13th.—Still continues the medicine. No return of pain in the knees ; greatly relieved in shoulders, etc.; the increased secre- tion from the skin and kidneys continues. The improvement continued up to the 16th, when she was dismissed for disorderly conduct. Commentary.—In this case the nitrate of potash, after being taken for three days, had caused much diaphoresis and diuresis, followed by diminution in the rheumatic pains, and rapid improvement at the time she was dismissed. Case CCLXXV.*—James Eough, set. 26, blacksmith, admitted December 29,1851. States that he has suffered on two former occasions from attacks of rheumatism. During his last attack, three years ago, he was treated in this hospital, and it lasted five weeks. The present attack came on nine days ago with great severity, having been preceded by febrile symptoms, which appeared to have followed exposure to cold ; the pain was very severe in all the joints, but especially so in the wrists and knees. He has noticed within the last year or two that considerable palpitation of the heart ensue3 after much exertion, or indulgence in ardent spirits; but in his or- dinary condition he is not troubled with it. At present the pain in the joints is not severe, unless on attempting motion ; pressure on the right shoulder and ankle causes considerable tenderness. The cardiac dulness measures a few lines more than two inches across; the apex strikes the thoracic parietes in the normal position. A very distinct bellows murmur accompanies the first sound, is heard loudest at the apex, and is not prolonged along the course of the great vessels; the second sound is more sharp and abrupt than natural. The radial pulse is not synchronous with the impulse of the heart, but follows it after a very appreciable interval. A few sibilant rales can be heard here and there over the chest. Tongue is slightly furred; appetite is impaired; thirst not excessive. There is slight diarrhoea. The urine is normal. Skin is moist, but no excessive perspiration. E Potass. Nitratis § ss; Aq. § vj. M. A table-spoonful lo be taken, diluted with much water, three times a day. Decem- ber 31st.—Pains much easier to-day. The bellows murmur is much softer also. Urine deposits some lithates. Is sweating a little to-day. Pulse 86, soft and regular. January 2d, 1852 (Thirteenth day).—Has no pain to-day. Continues to perspire a good deal; and the urine deposits a copious precipitate of the lithate of ammonia. Pulse 68, soft and regular. Complains much of weakness. After this date, the amend- ment continued uninterruptedly, although only one bottle of the Nit. of Potash mix- ture had been used, and he was dismissed cured on the 12th January. Commentary.—The employment of the nitrate of potash was followed by apparently marked effects in this case, producing diaphoresis and evident benefit on the twelfth day, and removal of pain on the thirteenth day of the disease. As the attack commenced nine days before admis- sion, we cannot suppose that the recovery was owing to the occurrence of a critical day. Besides, the good effects were apparent the day after the exhibition of the salt, and on the following day the pains had disappeared. The valvular murmur with the first sound at the apex, and the character of the pulse, could leave little doubt as to the mitral incompetency; and as he had been previously subject to rheumatism. there is every probability that the cardiac lesion was the result of pre- vious attacks of the disease. In a large number of cases which I have subsequently treated with nitrate of potash, I have satisfied myself that the disease is more readily subdued by this treatment than by any other. * Eeported by Mr. William Calder, Clinical Clerk. 988 DISEASES OF THE BLOOD. Treatment of Rheumatism by Lemon-juice. Case CCLXXVI.*—Abigail Eankin, a servant, ast. 39—admitted 15th Decemljor 1852. Had rigors on the 7th, followed by febrile symptoms and acute pain in all the joints. On admission, pulse 100, full and strong; heart sounds normal; considerable febrile symptoms; acute pains and swelling in all the joints increased on motion; much sweating at night. Other functions healthy. - Habeat Succ. Limonum §ijfer indies. On the 17th she was ordered 3j of Dover's powder. December 20th.—The pains have continued as acute as ever till to-day, although she has taken § vj of lemon- juice every twenty-four hours. At present she experiences somewhat less suffering on moving the joints. Habeat Succ. Limonum § iij ter indies. December 22d.—There was great sweating last night, and to-day she is much better. Habeat Succ. Limonum § i ter indies. Some swelling of the left wrist joint remained until the 23d, on which day all pain had left her. Dismissed well, January 6th, 1853. Case CCLXXVII.f—Catharine Eooke, set. 21, married—admitted December 23d, 1852. Had rigors on the 14th, followed by febrile symptoms and excessive pain, at first in the knees and ankles, but subsequently in every joint in the body. On ad- mission pulse 84, of moderate strength; heart's sounds and impulse normal; the joints are more or less swollen, painful on pressure and on motion; skin bathed with perspi- ration ; febrile symptoms, with the exception of increased pulse, well-marked ; a con- siderable deposit of lithates in the urine. Other symptoms noimal. E Pulv. Doveri gr. x statim sumend. B: Sol. Mur. Morph. 3 ss ; Potassa; Bitart. § ss ;-Sp. Aether. Nit. % j ; Aquce 3 j ; Ft. haust. hora somni sumendus. On the 25th, purgatives of calomel and jalap were ordered. Dec. 26th.—The pain and swellings of the joints have somewhat diminished, but are still very acute. Habeat Succ. Limon. §j ter indies. Jan. 2, 1853.—The pains have slowly subsided since last report, but there is still considerable soreness and stiffness of the knees. The arthritic swellings have everywhere disappeared. Jan. 4th.—Acute pain has returned in the right arm, which she cannot move. Jan. 5th.—Acute pain has extended to the right arm and back. Omittatur Succ. Limonum. B Potassce Nitratis § ss ; Aqua? § iv. M. Sumat § j ex aquce § iv ter indies. Jan. 6th.—The pains have now disappeared; marked improvement. No critical discharge. Dismissed well, January Vth. Case CCLXXVIII.f—Thomas Aitken, set. 30, blacksmith—admitted December 25th, 1852. Fourteen days ago, after exposure to cold, be was attacked by rigors, followed by febrile symptoms and pain in his joints, which have continued up to this date. On admission, pulse 74, rather weak. A blowing murmur with the first sound, loudest at the apex, which it seems resulted from a previous attack twelve months ago. Slight swelling only in his right hand and wrist, but there is pain in all the joints, more or less of an erratic character. Febrile symptoms very slight. Slight bronchitis. Habeat Succ. Limonum § ss ter indies. On the 28th, the dose of lemon- juice was increas.ed to §j. On Jan. 2d he was much better; but on the 4th the pains returned, but not so violently. On the 12th, he was free from pain, having had some diarrhcea, and taken a two-scruple dose of Dover's powder. On the 22d the pains returned, but again subsiding on the 24th, he was dismissed. Case CCLXXIX.f—James Ollason, set. 20, clerk—admitted January 4th, 1853, with organic disease of the heart of old standing, and chronic rheumatism of an erratic character, sometimes violently attacking one joint and1 sometimes another, accom- panied with swelling and tenderness. Lemon-juice in § j doses was tried three times a day, for four days; but, being evidently of little benefit, was then abandoned for opiates and sedatives. Commentary.—In no one of these four cases in which lemon-juice was given, although in two six ounces and in one nine ounces were taken daily, did it appear to me that the disease was in any way con- trolled or alleviated by the remedy. In Case CCLXXVI. six ounces were taken daily without any effect, and then the quantity was increased to nine ounces daily, until the 21st day of the disease, when sweating and resolution of the symptoms followed, more from natural crisis, per- * Eeported by Mr. F. M. Eussell, Clinical Clerk. f Eeported by Mr. Alexander J. Macarthur, Clinical Clerk. RHEUMATISM AND GOUT. 989 haps, than from the effects of the juice. In case CCLXXVII. the remedy was continued for ten days, and until the 21st day of the disorder was fairly passed. The nitrate of potash was given with the immediate effect of relieving the symptoms—although here also it is not improbable that a natural crisis of the disease was then established. In any case the inefficiency of the lemon-juice appeared manifest. Cases CCLXXVTII. and CCLXXIX. were cases of sub-acute and erratic rheumatism, which also resisted the lemon-juice; the first for a month, the second for four days. On the whole, this trial of the remedy was in no way favorable, and is strongly contrasted with the good effects of nitrate of potash, which I formerly brought before you. Case CCLXXX.*—Diaphraymatic Rheumatism. History.—John Eobinson, a bookbinder, set. 24—admitted February 5th, 1858. He says that on Sunday last, January 31st, he caught cold when at a funeral, and experienced some pain across the back and chest, especially on the right side. He felt extremely weak, and experienced great difficulty in breathing. On the following day he noticed an eruption on the extensor surfaces of both legs. Beyond a blister which was applied to the painful side, he has been subjected to no treatment. Symptoms on Admission.—Pain on inspiration over right side, laterally and pos- teriorly. Slight cough with scanty expectoration. Percussion good and equal on both side3. °On auscultation shght harshness of inspiratory murmur; pulmonary sounds otherwise normal. Pulse 110, soft. Tongue furred, but moist; bowels open; skin hot; perspires abundantly. The extensor surfaces of both legs are covered with urticaria. Other systems normal. To have scruple doses of nitrate of potash in half a tumblerful of water three times a day. Progress op the Case.—Feb. 8th.—Perspired profusely yesterday, and to-day there is a copious sediment of urates in the urine. The pain is greatly relieved. The urticaria is nearly gone, but there is an erythematous spot over each patella. Feb 15th.—Has now no pain, and complains of weakness only. E Quince Sulph. gr. i.; Acid. Nitric, m. x.; Aquce % j; M. Ft. haustus ter in die sumendus. Dis- missed well, March 10th. Commentary.—Deep-seated rheumatic pains in the chest are very apt to be mistaken for pleural or pulmonary diseases. In the present case I found most of the clinical clerks disposed to consider the disease a pleuro-pneumonia, and they had framed a report which gave con- siderable color to their opinion. A careful examination of the chest, however, convinced me that the lungs were sound, whilst the febrile symptoms, the pain on inspiration and its seat, satisfied me we had to do with diaphragmatic rheumatism. The treatment, therefore, was governed by this view of the case, and we saw the usual phenomena of critical discharge by urine and skin on the seventh day of the disorder. He was of weak constitution, however, and lingered in the house some time longer. In the same manner intercostal rheumatism is very likely to be mistaken by inexperienced persons for pleurisy, especially if they are not sure of the non-existence of friction or other physical sign in the chest, which their pre-conceptions have suggested to them exists there But if they carefully compress and rub the muscles between the ribs, while the chest is at rest, pain will be elicited even to a greater extent than occurs during inspiration; a symptom which is diagnostic Such cases formerly must have frequently been mistaken for pleurisy and bled of course with the effect of ultimately causing a cure. In agricultural * Eeported by Mr. Adolphe Baraud, Clinical Clerk. 990 DISEASES OF THE BLOOD. districts, slight intercostal or diaphragmatic rheumatism is most common at certain seasons of the year among laborers, who used consequently to be bled on a Saturday afternoon, rest all Sunday, and return to their work quite well on the following Monday. In such persons the vene- section was supposed by both practitioner and patient to have cut short an incipient pleurisy. Case CCLXXXL*—Rheumatic Iritis, followiny Acute Rheumatism— Recovery. History.—John Duffy, set. 25, Ordnance surveyor—admitted April 6th, 1857. Three weeks before admission, when in the pursuit of his occupation, he got wet, and a day or two afterwards was seized with rigors, followed by febrile symptoms, pains in all his joints, and swelling of both knees, and of the left elbow. After being in bed a fortnight and treated medically, he entered the Infirmary, where he took Pulv. Doveri and Tr. Colchici internally, and had Tr. Iodini apphed locally. On taking charge of the case in May I first administered Nitrate of Potash; subsequently he was ordered warm baths, and then quinine and wine with generous diet, under which treatment he became much better. Chronic pains, however, still continuing to linger about the joints, and especially the knees, cod-liver oil was ordered on the 25th of May, both internally and externally, and the quinine was discontinued. Occurrence op Iritis and Progress of the Case.—June 1th.— For three days has had slight redness of the conjunctivse, with watering of both eyes, for which he was ordered a zinc lotion. June 9th.—Conjunctivitis on the right side increased, and a small blister was applied over the right temple. June 10th.—Frontal headache. The conjunctiva, immediately around the cornea, is surrounded by a zone of straight vessels, radiating outwards. Inferior half of conjunctiva of uniform red color. To be cupped over right temple, and § v of blood extracted. Extract of belladonna to be apphed externally round the eye. June 11th.—The whole of right conjunctiva of a deep uniform vermilion, and zone of vessels round the cornea of a darker shade. Atropine to be dropped into the eye to ensure dilation of the pupil. To wear a large shade. June 13th.—Yesterday a weak lotion of Alum (gr. iij to § j of water) was applied, but has caused much irritation. Inner margin of iris thickened and irregular, pupil dilated. Discontinue lotion, apply belladonna externally, and a warm poultice over the eye at night. June 14th.—To-day iritis and conjunctivitis have appeared in the left eye. Much pain in head, and restlessness during the night. Appetite bad; tongue coated; pulse 76, moderate strength. To have Quince Sulph. gr. iij three times a day. To go into the side room, and the window to be obscured. June 11th. 'Left conjunctiva now of as uniform redness as the right, and iritis well developed; pupil, however, more dilated. Pelladonna has been applied round both eyes. Last night had § j of Castor-oil, which not having operated, was ordered to-day, Ol. Croton. gutt. unam et Ext. Colocynth. Co. gr. x. June 20th.— Both irides, which naturally are of a light-blue color, present a dark, dirty green color. The pupillary margins are thick, and that of the right side irregular, especially at one place where an adhesion has formed. Both conjunctivse are of a uniform dense vermilion color. There is considerable pain in the head; photophobia and lachrymation. Discontinue quinine. R. Pulv. Cinchon. Rubr. et Pulv. Sodce Bicarb, aa gr. v. Ft. pulv. to be taken three times a day. July 1th.—To-day the right eye is much improved, redness of conjunctivse diminished, adhesion of pupillary margin disappeared, and vision perfect. Left eye the same as before, but an adhesion has formed, which has rendered the pupil irregular for some days. Cephalalgia has been sometimes better, sometimes worse. Belladonna has been constantly applied. Applicent. hirudines iij tempor. sinist. July 14th.—The right eye is now quite well. Left eye appears if anything worse. The pupil is dim, greatly contracted, and its margin much thick- ened. Vision also is nearly gone; he sees as if through a thick cloud. Applicent. hirudines ij tempor. sinist. July 22d.—The leeches, he says, relieve the frontal pain, and they were again apphed yesterday. To-day conjunctivitis less, and evident improvement; pupil larger; vision clearer. July 28th.—Since last report the morbid appearances in the eye have gradually disappeared. Two leeches have again been applied, and a blister to the neck. General health much improved, although si ill Eeported by Mr. Stewart Lockie, Clinical Clerk. RHEUMATISM AND GOUT. 991 weak. August \0th.—Has been quite well for some days; vision in left eye is still slightly dim, but is getting clearer daily. Dismissed. _ Commentary.—This case of double rheumatic iritis, with conjuncti- vitis, was of the most severe description. So much, however, has been said about the danger of allowing such cases to run their natural course, and of the necessity of treating them with specifics, more especially with colchicum and mercury, that I resolved to treat this case without them. It was watched on this account with great interest by the clinical class, especially as it was seen from time to time by my friend, the ophthalmic surgeon to the Infirmary, who predicted the worst consequences. Yet notwithstanding the weakened condition of the patient when iritis came on, the severity of the disease in both eyes, and the apparent closure which was about to take place in one pupil, I persevered, and the result in perfect recovery justified my expectations. It may be argued, how- ever, that the case would have got well much sooner if mercurials had been given. It is very difficult to determine this point, because few oculists have informed us what is the ordinary course of a severe rheu- matic iritis with conjunctivitis. According to Wharton Jones,* if taken in time before much exudation has occurred, and properly treated, it may be cured in three or four weeks. What are called active remedies were not applicable in this case, even according to the principles of those who use them, and the amount of exudation was considerable. The complete recovery of the right eye, therefore, in five weeks, and of the left eye in six weeks, seems to me to have been on the whole a short period, considering all the circumstances, although on this point further observations are required. In the meantime, the case demonstrates that the most severe attacks of rheumatic iritis may get well, altogether inde- pendent of mercurials and active antiphlogistics. A similar conclusion had been previously arrived at by Dr. Williams of Boston, U. S., from a pretty extensive field for observation. (See p. 318.) I have now treated four other cases of rheumatic iritis in the Infirmary without mercury, and they have all recovered. Case CCLXXXII.f—Chronic Gout with Tophaceous Deposits in all the Joints. History.—Thomas Burns, a tobacco-pipe maker—admitted November 4th,^ 1857. Says he first became ill in Glasgow about ten years and a half ago, with pain and swelling in both his big toes. Soon afterwards the ankles and knees became affected. He was confined for a month, being unable to walk, or even to put on his shoes. Since then he has had on an average three such attacks every year, spring and autumn being the worst seasons; but he has rarely been confined by them more than a week. The attacks have generally commenced with rigors, followed by more or less fever and swelling in one or other of the joints. Almost every joint in his body has suffered in this way at one time or another. At the first attack, he says, chalk stones formed in his toes, and since then they have appeared in his feet, knees, elbows, and hands. The right hand especially has been much deformed by them. He is in the habit of cutting down upon, and extracting them, whenever they approach the surface and are unusually painful. He has been twice in the Infirmary, and on both occasions dis- missed relieved The present illness commenced suddenly six weeks ago, and has more especially'affected the ankles. He has undergone a great amount of treatment, havino- been bled and cupped, and having taken much medicine. He had been accus- tomed to drink a good deal of porter, as well as of spirits, until three weeks before his first admission, in June, 1856, since which time he has been more temperate. * Ophthalmic Medicine and Surgery, p. 150. \ Eeported by Mr. Wilkes, Clinical Clerk. 992 DISEASES OF THE BLOOD. Symptoms on Admission.—He complains of pain in the left wrist and both ankle joints, which latter are swollen, and pit on pressure. The joints of the fingers are nodulated and crooked, especially those of the right hand, hard to the feel, with numerous tophaceous deposits visible through the shining and stretched integument, about the size of millet seeds. The elbow and knee joints are similarly affected, with several deposits over the olecranon and patella of each limb. The toes are not so distorted as the hands. There is pain on pressure over the right lumbar region, with a slight trace of albumen in the urine. Other functions normal. B- Potassa; Acet. 3 iiss; Sp. Aether. Nit. 3 ss; Tr. Colchici 3 j ; Mist. Camph. ad § viij. M. § j to be taken three times a-day. Progress of the Case.—November 25th.—Small abscesses have appeared over the patella and heel, to which poultices have been applied. The mixture has been apparently of no service and is to be discontinued." Dec. 18th.—Last night was seized with severe lumbar pain, and general febrile symptoms, and on examining the urine it was found to be highly albuminous. The sediment contained numerous epi- thelial cells from the kidney, with granular and desquamative casts of the tubes. § v of blood to be extracted from the loins by cupping, and to have at night Pulv. Doveri gr. x. Dec. 21st.—Is much better. Albumen in the urine diminished. E Ammon. Phosphat. 3 j ; TV. Gent. Co. § j ; Inf. Cent. Co. § v. M. A fourth part to be taken in half a tumblerful of water three times a day.' Jan. 6th, 1858.—Since last report has been comparatively free from pain and doing well, but last night was again seized with severe febrile symptoms, accompanied by painful sensations throughout his body. To-day the joints of the extremities, especially those of the hands, are very painful. The hands to be poulticed. To have Sol. Acet. Ammon. 3 j every hour. Jan. 8th.— He has been perspiring much, and is better, although pains in joints are still very severe. The poultices have brought away several fragments of the tophi near the surface. They are of a pale yellow color, friable, and when examined under the micro- scope present a mass of needle-shaped crystals of urate of soda. E Ammon. Phos- phatis 3 ss; Tr. Colchici 3 j; Aquce % vj M. A third part to be taken three times a day. Jan. 22d.—The pains in the joints have now been absent for ten days, and he was dismissed. Commentary.—The above is only the third case of gout I have seen in the wards of the Royal Infirmary, and it is a matter of general obser- vation that the disease is one from which the people of Scotland are re- markably free. This has generally been attributed to their frugal habits, but more especially to the drinking of whisky, instead of malt liquors and wines. Dr. William Budd has described gout to be common among a class of workmen on the Thames, whose occupation it is to raise ballast from the bottom of the river. " Those men," he says, " drink from two to three gallons of porter daily, and generally a considerable quantity of spirits besides." * Now, it is curious that this is what the man, whose case is before us, seems to have done, and to this habit, therefore, we may fairly ascribe the occurrence of the disease. He admitted that for some years he was accustomed to drink upwards of half a gallon of porter, besides from four to eight ounces of whisky daily. There was no hereditary tendency. The numerous local attacks frequently gave rise to excretion of the morbid products by the kidneys, with all the symptoms of Bright's disease, including albuminous urine, and desquamation of cells with casts of the tubuli. In a week or so, however, they disap- peared, and he enjoyed a temporary immunity from uneasiness. As to treatment, nothing seems to have been of permanent benefit, the topha- ceous deposits apparently keeping up more or less irritation and tendency to local attacks, which in their turn excited constitutional ones, more especially the fever and urinary symptoms. * Library of Medicine, vol. v., p. 219. SCORBUTUS. 993 SCORBUTUS. Case CCLXXXIH.*—James Dermot, set. 21, railway laborer—admitted May 27th 1847. Has been working on the Caledonian line of railway for nine months, and enjoyed good health till three months ago, when he received a blow on the right tibia. This produced a sore, and an ulcer formed. His diet consisted of bread, coffee, ham, butter, and sugar; but no milk or fresh vegetables. On admission, an elliptical-shaped ulcer, about two inches in length, is seated over the middle of the tibia, covered with irregular livid granulations, and surrounded by a raised purple edge. Another ulcer, the size of a shilling, is seated below this, and a third similar one on the outside of the leg. Eighteen months ago his left leg was burnt, and over the seat of the old cicatrix a number of ulcers, similar to those on the opposite leg, exist. One of these, towards the lower part of the leg, is the size of half-a-crown, and more livid than the others, which are smaller. The gums are swollen and fleshy, but not livid. Pulse 74, soft. Bowels constipated. To have full diet. E Aluminis 3 i; Aquce % viij. Solve. Ft. Gargarisma. E Sued limonis 3 iij ; Sacchari |iss; Aquce § iss. M. Sumat pro potu ex aqud indies. June 2d.—Ulcers looking more healthy. Their surface to be touched with nitrate of silver. July 21th.—Has slowly got well since last report, and is now discharged. Case CCLXXXIV.*—John M'Kenzie, set. 26, railway laborer—admitted July 7th, 1847. During the last two months his diet has consisted chiefly of coffee or tea, with bread, butter, and sugar, but no milk. Two weeks ago pain and swelling came on in his left leg. Soon afterwards the right leg was also affected, and both became dis- colored. ' Epistaxis now occurred, and has continued at intervals ever since, and has been so severe during the last two days that his nostrils have been plugged. On admission, the left leg is much swollen, and of a purple color chiefly on its anterior and inner aspect. The right leg is similarly affected, but to a less degree. Ho com- plains of pain and stiffness in both limbs, especially about the ankles. The gums are slightly swollen, and livid at the edges, but do not bleed on masticating food. Pulse 80, soft. Tongue clean. Bowels regular. To have full diet. July 20th.—Since ad- mission the symptoms have gradually disappeared, and to-day he was dismissed cured. Commentary.—During the year from October 1846 to October 1847 no less than 231 cases of Scorbutus entered the Royal Infirmary, of whom 30 also labored under continued fever. Of the entire number, nine were females, and seven died. In the previous year only one case entered the Infirmary, and in the following one only six. I myself treated between seventy and eighty of these patients, having succeeded Dr. Christison in the charge of a long shed which contained a large number of them, besides seeing others who came into my other wards. At the same period, there existed a most extensive epidemic of typhoid or typhus fever. Yet it is singular that the causes which produced scurvy, mostly in the able-bodied population, and especially among the class of laborers or " navvies " then working on our railways, were of a kind distinctly different from those usually giving rise to continued fever ■ the potato crop had failed for two successive seasons, and caused amon* the poorer population the consumption of a diet, not only deficient in vegetables, but of milk and fresh meat also. Among the railway laborers the truck system, and establishment of local stores where provi- sions of'inferior quality were given on a ruinous system of credit or ex- change, greatly assisted the absence of vegetables in causing the disease The previous winter had been severe and protracted; so that whilst food of all kinds was high priced, the work and exposure of the-labonng popu- lation were unusually severe. But scanty and improper diet, and * Eeported by Mr. J. Eobertson, Clinical Clerk. 63 994 DISEASES OF THE BLOOD. especially such a kind as was deficient in fresh meat, milk, or vegetables, could in almost every case be ascertained to be the cause of its occurrence. Accordingly in a large proportion of the cases it was found sufficient to give the full diet of the house (Case CCLXXXIH.), to which in unusu- ally severe cases, two or three ounces of lemon-juice with wine were added (Case CCLXXXIV.) This if the individual was not too prostrated before admission, produced a cure in a period varying, according to the intensity of the disease, from three to six weeks. Most of the cases entered the house between the months of January and August. Dr. Christison, who has given a most able history of the epidemic as it was observed in Edinburgh and in the Perth Penitentiary,* conclu- sively shows that to the absence of milk, or its equivalent nitrogenous constituents, much of the disease was owing. In the Perth Penitentiary treacle water had been given instead of.it, and on restoring the milk no fresh cases occurred. Dr. Lonsdale again showed that in the agricultu- ral valleys of Cumberland milk was abundant,! and that the absence of potatoes and fresh vegetables was the evident cause. The probably cor- rect conclusion is, that health demands a varied diet, and that a too rigid abstinence from milk and fresh meat as well as from vegetables may oc- casion the disorder. The observations of Dr. Christison unquestionably prove the anti-scorbutic properties of milk, and of the full diet of the Edinburgh Infirmary, as these very frequently constituted the only treat- ment of individuals who recovered rapidly. The following table shows the nutritive proximate principles in ounces I. HEALTHY. 1. Scott. Prison standard 2. Glasgow Pris'n, 3d rate 3. Edinburgh Prison, do. 4. Millbank Prison, 1821 5. Do. Convicts, 1840 . 6. Dublin Bridewell, 1847 II. CONVALESCENT. 7. Edin. Inf. full diet . 8. Fever conval. diet . III. SCORBUTIC. 9. General Prison, 1846 10. Mtilbank Prison, 1823 11. Do. Soldiers, 1840-41 12. Do. do. improved, 1841 NON-NlTEOGENOTJS. NlTEOeENOTJS. Total. Starch. Sugar. Fat. Gluten. Legum. Album. Casein. Mus. flu Total. 25-2 25.0 24-3 25-0 23-1 19-5 19-4 20-1 24-2 20-9 18-9 19-2 17-8 18-2 17-8 19-4 17-9 13-4 11-6 11-1 17-8 16-6 15-3 35-0 1-32 0-82 1-56 003 1-10 1-50 1-56 0-11 0-16 0-13 0-55 0-57 0-60 1-26 3-88 1-11 0-20 0-38 0-38 396 4-07 3-89 3-01 3-06 2-93 2-36 1-82 3-96 3-80 2-97 3-04 0-13 0-13 0-25 0-47 0-13 0-23 0-21 0-03 0-04 0-04 036 023 001 0-49 0-03 0-04 1-36 1-36 0-38 0-40 1-57 1-50 0-03 0-07 0-55 0-23 0-23 1-21 0-99 0-94 1-65 2-16 0-55 0-30 0-78 0-64 6-03 5-83 4-79 5-05 4-74 5-49 5-52 4-40 4-40 3-98 3-78 3-89 Note.—1, 2, 3. The standard third-rate diet of the Scotch prisons, as used in the General Prison at Perth, in healthy years. 4. Diet of Millbank Penitentiary, London, before being changed to No. 10. 5. Millbank diet of civil convicts, who remained free of scurvy, while the military prisoners were attacked under the diet, No. 11. The data given by Dr. Baly, physi-cian to the prison. 6. The present diet of the Dublin Prison, where male convicts are kept for long terms. 7. Edinburgh Royal Infirmary fuU diet, under which scorbutics promptly re-covered. 8. Convalescent diet of a fever patient of the wealthy ranks, rapidly recovering flesh and strength. 9. Diet of the General Prison before the scurvy broke out. 10. Ditto before the Millbank epidemic at London in 1823. 11. Ditto before the military prisoners in Millbank Penitentiary were attacked with scurvy in 1840-41. 12. Improved diet on that occa-sion, but found ineffectual. The individuals subjected to the dietaries in the I. and III. Divisions were all in confine-ment for long terms.—(Christison.) * Monthly Journal of Medical Science, June and July 1847. See also Dr. Eitehie on Scorbutics, as it appeared in Glasgow at the same time. July and August 1847. f Op. Citat., August 1847. POLYDIPSIA. 995 avoirdupois of the various dietaries, healthy, convalescent, and scorbu- tic. Dr. Grarrod,* from an examination of the composition of food, under the use of which scurvy was capable of occurring, as well as of such substances as had been proved beyond doubt to be anti-scorbutic, was led to the conclusion that the absence of potash was the cause of scurvy. In this way he shows—1st, That potash is deficient in scorbutic diet; 2d, That all bodies proved to be anti-scorbutic, including fresh meat and vegetables, milk, lemon-juice, etc., contain a large amount of potash; 3d, That in scurvy the blood is deficient in potash, and the amount of that substance thrown out by the kidneys is less than what takes place in health; 4th, That scorbutic patients, when kept under a diet which gave rise to the disease, recover when a few grains of potash are added to their food. The salts of potash, such as the nitrate, oxalate, and bi- tartrate, are well-known anti-scorbutics, but the efficacy has always been ascribed to the acid rather than to the alkali; 5th, That deficiency of potash in the system seems capable of explaining some of its symptoms, especially muscular weakness, as potash is a necessary constituent of the muscular system. These views undoubtedly merit attention, and it is much to be regretted that they were not made known until the epidemic which had called them forth had disappeared. POLYDIPSIA. Ca.se CCLXXXV.f—Sudden Polydipsia—Incurable. History.—Margaret Shearer, a French polisher, set. 34—admitted May 31st, 1854. States that a year and a half ago she went to work at six o'clock, a.m., in her usual state of good health, and at eight o'clock, two hours afterwards, was suddenly seized with great thirst, which has continued ever since, accompanied by excessive discharge of urine. About three months afterwards she was obliged to give up work on account of a pain in the loins. At various times she has experienced loss of appetite, nausea, fulness of the abdomen, palpitations, constipation, or diarrhoea. Thinking that her strength had diminished of late, she entered the Infirmary. Symptoms on Admission.—On admission, the amount of urine passed in twenty- four hours was 424 ounces—pale in color—of sp. gr. 1005, not coagulable by heat or nitric acid, and containing no sugar, as determined by Trommer's test. She is a stout able-bodied woman, and speaks of occasional shght complaints. She has a pale coun- tenance furred tongue, and dry skin ; but in every other respect is quite healthy. Dr. Alison who first treated her, ordered warm baths and astringents, and afterwards galvanic shocks to be passed through the epigastric region. On taking charge of the case in the middle of June I ordered hitter tonics, and the diet was carefully arranged, and the amount of water drank limited, and mixed with milk and a little magnesia. No chanee however, occurred, and she confessed that she could not admit of restraint with regard to the amount of drink. During the whole month of July she was weighed daily and the amount of water drank and emitted from the kidneys carefully measured Her average weight was eight stone, which underwent little variation. The amount of water drank varied from 370 to 520 ounces, the average being 440 ounces The amount passed varied from 350 to 500 ounces; and it was observable that it'was always from 20 to 50 ounces less than the quantity drank. The sp. gr. varied from 1001 to 1005, and was frequently tested for sugar, with the uniform result of its never being detected. The bowels were generally open every other day, and the stool was of normal consistence and healthy appearance. ' pr0GRESS of thE CASE.-From the 9th to the 14th of July I tried the influence of narcotics and she took three grains of opium daily, with 3 iss and then 3 ij of solu- tion of morphia. Under this treatment she frequently appeared drowsy and stupid, -------------* Monthly Journal of Medical Science, January 1848. f Eeported by Mr. James Thorburn, Clinical Clerk. 996 DISEASES OF THE BLOOD. but sound sleep was never prolonged, and no diminution of the thirst and diuresis was perceptible. She then took large doses of gallic acid, and subsequently, at her own request, cod-liver oil, under the use of which she became stouter, stronger, and the appetite improved. August 22d.—All other treatment was suspended, and she was ordered to take ten minims of the liq. iodinei comp., which was continued to the 14th of September without any effect. On the 16th she was ordered ^ Mass. pil. aloes et myrrhce 3j; Fern, sulph. 3 ij.; Ext. hyoscyam. 3ij. Ft. massa in pil. xij dividenda. Two pills to be taken twice daily. On the 26th there was diarrhoea, when the pills were discontinued, and an astringent mixture ordered. The report on the 1st of October was—" general health, good," and from an observation made for the first seven days of this month, it appears that the thirst and diuresis had somewhat diminished, the amount of urine varying from 280 to 350 ounces. There was no further change up to October 10, when she left the house. Commentary.—I prefer calling this case polydipsia to diabetes insi- pidus, as frequent careful inquiry established the fact that it commenced with thirst, and that the increased flow of urine was a simple result of the quantity of water drank. In the present state of science no reason- able theory can be conceived explanatory of the fact, that a woman, apparently in good health, is suddenly seized with great thirst, and thereupon drinks two or three gallons of water daily, passes a corre- sponding quantity of urine, and that this continues for nearly two years without any marked change in her health. Where there is no scientific indication, the treatment is wholly empirical, and even the results of experience are wholly negative and useless. Astringents, diaphoretics, galvanic shocks, narcotism by means of opium, cod-liver oil, iodine, and purgatives, all failed. The latter, by increasing the alvine discharges, diminished somewhat the excretion of urine, but we could not flatter ourselves that she was in any way benefited by her four months' treat- ment in the Infirmary. Case CCLXXXVL*—Polydipsia during the last two months of Preg- nancy—Disappearing after Delivery. History.—Mary M'Donald, set. 34, married—admitted November 25th, 1860. She is now in the seventh month of pregnancy, and two months ago her attention was di- rected to a strong craving she experienced for drinking water. She frequently took two or three tumblers full at a time, and during the twenty-four hours swallowed half a pitcher full, or about 200 oz. This has continued ever since, and latterly she has been troubled with cough and expectoration. Symptoms on Admission.—Her digestive system is in every respect healthy, with the exception of inordinate thirst, which is greatest in the morning, and after every meal, even when for the most part fluid, as tea. Before she drinks there is expe- rienced a sensation of dryness in the mouth, tongue, and fauces, and a feeling of dis- comfort arises if prevented from gratifying her desire. Three or four tumblers full of water generally cause satisfaction and a feeling of satiety. She passes a large quantity of urine, which is voided frequently. The desire to micturate comes on immediately after drinking a large quantity of water, and the fluid is passed in a full and prolonged stream, over which she has no control. Percussion over the chest is everywhere resonant, but on auscultation, loud sibilating and sonorous rales are heard with expira- tion, on both sides over the upper two-thirds of both lungs. Cough severe and paroxysmal. Sputum copious and watery. Pulse 104, weak. Skin dry. Other functions normal. B- Sp. Aether. Sulph. 3 ij ; Chlorodyne 3j; Mist. Scillce c. § vj M. Ft. Mist. A table-spoonful to be taken when the cough is troublesome. Progress of the Case.—During November and December the bronchitis gra- dually got better, and had disappeared on the 20th of the last-named month. She drank, in addition to a certain amount of fluid taken at meals, from 90 to 130 oz. of * Eeported by Mr. Kenneth M'Leod, Clinical Clerk. POLTSAECIA OE OBESITY. 997 water daily, and passed from 130 to 250 oz. of urine, clear and watery-looking, sp. gr. 1003. _ December 21th.—She was delivered of a healthy boy, the labor being natural and quick. December 28th.— Her thirst and dryness of mouth have greatly dimin- ished. December 29th.— Has no thirst; urine only 50 oz. She recovered rapidly. The polydipsia has disappeared, and she passed from 40 to 70 oz. of urine daily up to 3d of January, when she, with her infant, was dismissed quite well. Commentary.—In this case the same condition existed as in the last, but not to the same extent. Her pregnancy forbade all active remedies, and no curative trial was made. She informed us that during the latter period of her previous pregnancy the same excessive thirst had occurred which immediately disappeared after delivery. I therefore merely treated the bronchitis, and we saw the polydipsia cease on the birth of her child. POLYSARCIA OR OBESITY. Case CCLXXXVIL*—Great Obesity—Fatty Degeneration of Heart and Muscular System generally—of Liver and Kidneys—Hyper- trophy and Dilatation of Heart. History.—Anne Gilchrist, aet. 42, a cook—admitted June 17th, 1857. With the exception of an attack of rheumatism when 13 years of age, she has enjoyed good health until three years ago, when she ruptured a blood-vessel in the lung from over- exertion. Last March she caught a cold, and shortly afterwards observed a swelling of the feet, gradually extending up the extremities. Since then she has suffered much from dyspncea. She has been of a full habit of body since the age of thirteen; has indulged largely in eating and drinking; besides spirits, having drank at least a bottle of porter daily. She has always been exposed to large fires in the kitchen, and in con- sequence of corpulence, has taken Uttle exercise. Symptoms on Admission.—The woman is of an unwieldy size from corpulence. The circumference of the body at the umbilicus is 61 inches, of the calf of the leg 20 inches, and of the ankle 13 inches. She can lie on either side, but is very uneasy on the back. Shght exertion produces dyspnoea. The sounds of the lungs and heart are normal. Percussion of the latter organ is unsatisfactory, in consequence of the un- common size of the left mamma, and accumulation of fat. Pulse 82, regular and of good strength. Tongue covered with a thick fur. Appetite good. Urine scanty and turbid, sp. gr. 1015, albuminous on being heated. The skin over the abdomen and lower 'extremities is indurated and coarse. The scales of the house will only weigh 25 stone, and she is much heavier than this. To have a scruple dose of Bitartrate of Potash three times a-day. Full diet and 4 oz. of wine daily. Progress of the Case.—June 21st.—Since admission pulse better, and passes more urine__yesterday voided 30 oz. July 9th.—Has passed from 20 to 30 oz. of urine daily, and the legs have ceased to be oedematous. Complains of loss of appetite. Pulse 80, weak. To have § vj. of wine daily. July 10th.—Urine again scanty, only passed 10 oz vesterday. To have a squill and digitalis pill three times daily, in auc- tion to the powders. July 11th.—At the visit to-day found lying on the right side, too weak to raise her head, and breathing with difficulty, the respirations being short and labored. The urine was again deficient in quantity, and there was constipation. A drachm of the compound Jalap powder was ordered to be taken immediately. In the afternoon before the powder had operated, she suddenly grew livid in the face, a tracheal rattle was heard, and in two minutes she expired. Sectio Cadaveris.—Forty-four hours after death. External Appearances.—Body of enormous size, owing to excessive development of adipose tissue. The head appeared to emerge without any neck from the trunk. Mammas enlarged, each above the size of an adult's head. The foUowing measure- ments were taken:—_______________________________________________________ * Eeported by Dr. John Glen, Eesident Physician. 998 DISEASES OF THE BLOOD. 65| inches. 54 „ 36 ) 69 36 J 19 16 28 ) 20| 13 ) 2 5 J Height .... Circumference of chest below nipple Breadth from shoulder to shoulder Circumference of abdomen mammae at base upper arm lower arm thigh . leg below the knee ankle Thickness of integument over sternum ,, „ abdomen Thorax.—Heart much enlarged; it weighed 22 oz. All the cavities were dilated, the walls retaining their normal thickness. The valves were healthy. The muscular tissue of the heart was pale and soft. The lungs were healthy. The osseous walls of the thorax were not larger than usual, the breadth internally being 11-J- inches. Ardomen.—There were two ounces of serum in the peritoneal cavity. The liver was much enlarged, Weighed 7 lb. 10 oz., and was of a pale fawn color. The two kidneys weighed 13£ oz. They were of soft consistence and pale color. The spleen weighed 13£ oz.; it was softer than natural. The intestines were healthy, and with the exception of a few cysts in each ovary, the other viscera were normal. Microscopic Examination. — The muscular tissue of the heart was seen to be in an advanced stage of fatty degeneration. The cells of the liver were crowded with large drops of oil, and the nuclei of many of them were absent. The cells of the kid- ney were also very fatty. Commentary.—The circumstances in which this poor woman was placed were exactly those most favorable to the production of obesity. As cook in several noblemen's families, there had been no necessity for her undertaking much personal exertion, and having a good appetite and sound digestive organs, she indulged largely in eating and drinking, whilst always more or less in a heated atmosphere. It is much to be re- gretted that her exact weight was not ascertained. When standing on the Infirmary scale, which only allowed us to weigh to the extent of 25 stone, it seemed as if she was at least 5 stone more. In a table of obese persons given by Dr. T. K. Chambers,* one man is said to have weighed 36 stone, but he was 6 feet 1 inch high ; two others, a man and a woman, weighed 28, and another woman 26 stone. In the case before us the increase of fat had certainly arrived at an extent seldom witnessed in the human subject, and with the result of gradually causing fatty degenera- tion of internal organs essential to life. Latterly, from fatty degenera- tion of the kidneys, albuminuria made its appearance, with oedematous limbs. From this, however, she might h.ave recovered, had not the ad- vanced fatty degeneration of the heart and liver so enfeebled the circu- lation as to render fatal syncope at no distant period certain. It is probable that the change of diet and absence of her accustomed stimuli contributed to the result, although every care was taken to counteract such causes of exhaustion as much as possible. Mr. Banting, in a pamphlet on Corpulence, London, 1864, tells us, that acting by the advice of his medical attendant, he reduced his weight iu twelve months from 202 lbs. to 156 lbs., by abstaining from bread, butter, milk, sugar, beer, and potatoes. Though this plan of diet un- questionably diminishes obesity, care should be taken to adapt it to the exigencies of particular cases. The not following this precaution has already led to injurious effects in many persons (see p. 322). * On Corpulence. 1850. P. 139. CONCLUSION* The Ethics of Medicine. Gentlemen,—After a lengthened period of study, and a series of examinations, intended to test the amount of your knowledge, you have received the degree of Doctor in Medicine, the highest academic honor it is in the power of any University to confer. The direct connection which has hitherto existed between you and your teachers here termi- nates, and all those restraints which public opinion and legal forms have imposed upon the uneducated are removed. The energies which you have hitherto employed in acquiring the necessary preparatory informa- tion you may now dedicate to the practical affairs of life. In short, gentlemen, you this day obtain a high status in society, and without, 1 hope, ceasing to be students, you become members of a liberal and highly honorable profession. Such an event constitutes an important epoch in the life of every man, and is well calculated to excite not only deep feelings of reflection in yourselves, but those of lively emotion in all who are concerned (and who is not ?) in the progress of that art which is directed to the prolongation of life and the cure of diseases. It will not, then, be considered superfluous if, in obedience to established usage, before you leave this institution, a member of the medical faculty seizes the opportunity of offering to you a few words of advice, of point- ing out the importance of your future profession, and describing to you the spirit in which it ought to be practised. I. The first piece of advice that I shall take the liberty of offering is, always to clierish a feeling of deep responsibility. A medical man is the earthly arbiter of life and death. He is the guardian of our race through the dangers of birth and the perils of infancy. He is called upon to treat the different maladies which can afflict the human frame, under every circumstance of climate, age, sex, or condition ; and lastly, when all means fail to prolong life, it is his duty, if possible, to alleviate those pangs and diminish those sufferings which accompany the separation of the soul from its present dwelling-place. If, then, we regard him as the soother alike of the entrance and the exit of this life,- as the first and the last friend of frail humanitv, and if We further consider him, in the social scale as the superintendent of all public and private institutions for the sick and the insane, as the adviser of legal tribunals in the administra- tion of iustice, and as the regulator of the sanitary conditions of armies, fleets and indeed, of nations, it is scarcely possible to conceive a voca- tion in which every feeling of duty and honor ought to incite to activity * An address delivered as Promoter of the Medical Faculty to the graduates in medicine. August 1, 1849. 1000 CONCLUSION. and usefulness; to the cultivation of his intellectual powers and resources; to a life of beneficence and integrity, and above all, to a sense of the deepest responsibility. This feeling is one which the most experienced and able practitioner can scarcely shake off, and which ought to press, with enormous force, upon those who are newly called upon to decide concerning the awful affairs of life and death. A fellow-creature having received some violent accident, or being attacked by acute disease, calls upon you for assistance. There may be no more experienced practitioner near; there is none to consult with; the danger is imminent, and you feel conscious that not only something must be done immediately, but that what is done may save or destroy. Then there rushes upon your mind a peculiar feeling of dread and anxiety, rendered more embarrass- ing, perhaps, by the conviction that your future prospects may be in- fluenced by the manner in which you conduct the case before you. Such a circumstance as I have supposed may happen to any of you at the com- mencement of your career, and it is then you will perceive, that the only true support to be depended on is a consciousness that you are enabled to put in practice all those means which the present condition of the science and the art of medicine have recognised as being correct. At such moments there will be impressed upon you the conviction that the good of your patients, and your own mental tranquillity, are intimately united; you will see the advantage of having studied your profession, not merely as an object of gain, but from a love of its intrinsic excellence —not because it brings you consideration and respect, but because it en- ables you to do good and to relieve suffering—not with a vain effort at exhibiting your superior knowledge, but with that humility which is the necessary result of true wisdom. The object of medicine is to preserve health, prolong life, cure diseases, and thereby to forward the happiness of mankind; and it is evidently the duty of those who practise it to lose no opportunity, and to adopt every means of prosecuting that object to its fullest extent and in its widest signification. With this view, gentlemen, your past studies have been directed to the acquirement of various kinds of knowledge, the purpose of which has been not merely the obtaining of professional rules, but en- larging the mind and cultivating the reasoning powers. The time has now arrived when you must concentrate the miscellaneous information you have, gathered together, in order better to carry out that particular kind of practice which you in future intend to pursue. Any of the so- called accessory sciences may (should your tastes allow) be still further prosecuted, but not to the exclusion of more important matters. Your duty is to cure the sick and relieve suffering, and not to be distinguished as a chemist, a botanist, or a naturalist. Neither is it expected that you should have all the knowledge which each of your teachers possesses in his especial department, but that from the whole you should have obtained such a sum of learning, and such an available kind of information, that you may undertake the serious duties of a medical practitioner with credit to yourselves and advantage to the public. Such an amount of knowledge is within the reach of all; and should there have been any deficiencies or omissions in your past career, you are imperatively called upon to remedy them at once. Perhaps it is unnecessary for me to sav THE ETHICS OF MEDICINE. 1001 your education^ not complete; indeed, in one sense, it may be said to be only beginning. Hitherto, you have depended on others, now you must advance by yourselves—the information of collegiate life must be perfected and elaborated, in order to meet the exigencies of every-day affairs. You must prune away those imaginings in which the student loves to indulge, and direct your thoughts to the stern realities before you. For this purpose, you should seize the interval which may elapse between your retirement from the schools and the commencement of actual practice, in arranging your past acquirements for ready use, and in extending, by every possible nieans, your experience in the observation and treatment of disease. By so doing, I consider you will be best qualified to meet_ the serious responsibility you have to undertake, and will thereby attain that comfort of mind and true respectability which the proper and enlightened exercise of our noble profession can alone secure. II. This leads, me, in the second place, to impress upon you the importance of practising the art and cidiivating the science of medicine in a spirit of sincerity and of truth.—It is a well-known fact, that whilst the public can judge with tolerable correctness of merit in any other profession, it is wholly incapable of forming an estimate of ability in medicine. The structure of the human body, the functions it performs, the laws which regulate it, and the derangements which affect it, are to mankind in general completely unknown. All that your patients will concern themselves with are results—but so ignorant are they of the means by which results are obtained, so little do they know of the opera- tions of nature as distinguished from those of art, that they are especially liable to be led into erroneous conclusions. In consequence; unprincipled persons, from time immemorial, have successfully practised on public credulity, and some specious but shallow theory, some vaunted nostrum, some peculiar accomplishment, or some singularity of manner, have each in turn been made the means of imposition. It is expected of you, gentlemen, that you are so well grounded in the facts and principles of medicine as to be enabled, on all proper occasions, to put down ignorant presumption, refute false doctrines, and expose artful knavery. You will remember that medicine is a progressive science, and that whilst the wise and learned who have cultivated it have done much, more remains to be accomplished. You will therefore readily acknowledge its imperfections where such truly exist, and prefer a frank avowal of ignorance to a false assumption of knowledge. There is one great difficulty you will have to encounter, viz., that the rules and principles which guide the profession in the course of time undergo a considerable variation. The. arts and luxuries of life, the physical changes of the globe, and the differences of education and civilisation to a certain extent modify the constitution of man and the diseases to which he is subject. Maladies described as existing in former times are now unknown, whilst others are altogether of modern origin. It is of the utmost consequence, therefore, that the medical practitioner should be alive to the importance of following the progress of his art and not imagine that at any time he has learnt all that is 1002 CONCLUSION. useful, or that he can ever reach that point at which improvement is not to be gained. At the same time, he must learn, amidst the multitude of suggestions, the number of theories, and the opposing statements which will perplex him, to reject what is worthless, and only adopt what is truly useful. In all such cases, the best rule is to be on your guard against loose and confident plausibilities, especially where such are advanced, not in their true character as hypotheses, but as estab- lished laws which are to regulate your practice at the bed-side. It is sometimes allowable to give a certain rein to the imagination, and cultivate that power of generalisation which has led to the most im- portant and brilliant results in science; but if this be not controlled within its proper limits, nothing can be more mischievous, especially when the errors may affect the lives of mankind. Strive, then, so to improve your intellectual resources and observing powers, that you may be enabled to shun error and admit truth, especially avoiding all those easy and fallacious paths to knowledge into which the interested endeavor to entrap the unwary. A desire to practise your profession in sincerity and truth will also lead you, in cases which you have not particularly studied, or which demand special kinds of treatment, to require the assistance of some brother practitioner. No two persons prosecute their study in exactly the same direction; and the subject of medicine is so extensive, so complicated, and requires so much application, that it is almost im- possible for a single individual to become master of the whole. Vanity and self-conceit, it is true, have led some men to maintain the con- trary ; but where is the individual who is at the same time a good physician, a good surgeon, and a good obstetrician ? There are many, doubtless, who practise very usefully in all these branches, and you may be so circumstanced hereafter as to do the same. If so, you will necessarily be often consulted in cases where you must feel internally convinced that you cannot do full justice to your patient, and then it will be right to bear in mind that, if you possess a greater share of information in some respects than others, they in certain particulars know more than you. Do not, then, be deterred by a false feeling of shame, or a desire for gain, from consulting your medical brethren; reciprocal services beget mutual kindness, and it is at all times better to resign the treatment of a case you do not understand, than subject yourselves, by undertaking it, to a perpetual series of mortifications and disappointments. By exercising your profession, then, in a spirit of sincerity and truth, you will be animated by a proud desire to advance its claim to public confidence, rather than your own immediate interests; ycu will despise the miserable vanity of announcing what is new, with- out a scrupulous regard to its being correct. You will, while retaining the right of thinking boldly for yourselves, not forget that observation is difficult, theory imperfect, and experience frequently fallacious. You will not, therefore, rashly substitute your own authority for that of those whose knowledge is more extensive, or commit yourselves to the ephemeral doctrines of the day, by which a few otherwise respectable men have lost their professional reputation. You will remember that the conclusions of youth are almost always modified by the experience THE ETHICS OF MEDICINE. 1003 4 of age,* and that the wisest and most eminent men of science have given the best proofs of a solid understanding by the readiness with which they have acknowledged their own ignorance. III. The third and last point to which I shall direct your atten- tion is, that you ought to be strongly imbued with a sense of duty and of moral obligation. No profession demands that its members should be governed in their practice by purer principles of honor than our own. The medical man is received into the bosom of private families, where he is intrusted with matters of such a nature that, if they were dis- closed, they would be attended with the greatest distress, and would plunge parents or children into the most bitter and poignant agony. It is your office not only to regulate the corporeal, but, in many cases, the mental derangements and irritability of your patients; but who can govern the minds of others if he is incapable of commanding his own ? Prudence, sobriety, kindness, and delicacy of feeling, are there- fore especially enjoined upon those who treat the sick. It is true, you will labor among scenes of woe, and have to watch incurable diseases and loathsome maladies ; but he whose sensibility is thereby blunted, and who can look with indifference on the agonies of a fellow-creature, will seldom feel that anxiety, or experience that watchfulness, which is so necessary for detecting the true condition of his patient. Self- interest is the worst of all models for a medical practitioner, and is a vice which our profession may proudly claim exemption from. You, I trust, will never experience it, but rather those pleasurable emotions which result from lessening human suffering, without thought of profit, and from exercising friendly offices with that politeness and delicacy of sentiment which distinguish every man of a gentlemanly and refined mind. Mixed, as you occasionally will be, with every branch of society, you must expect sometimes to meet with ingratitude, and be ignorantly and undeservedly charged with committing errors. All men are liable to misrepresentation; and although I do not, at such periods, advise you quietly to submit to insult, I strongly recommend great cir- cumspection in manifesting resentment. " Unjust suspicions may attach to an innocent man; the general consistency and integrity of his life will wipe them away; the imprudences of youth may be repaired \>y the circumspection of middle age ; but if you once lose your reputation for professional prudence and honor, you will find, whatever be your at- tainments, that your influence is gone, and that you are, in all respects, lost and ruined men." In addition to the duties which you discharge to the public at large, there are others of no less importance which you owe to your- selves. Opportunities will frequently occur where you may, by looks or words seriously injure the reputation of some brother practitioner, when in reality he does not deserve it. The period of the disease, or the circumstances which have occurred, may enable you to do what your pre- decessor could not. Every good feeling demands that under such circum- stances you should explain the cause of your success to the patient, and not allow him to suppose his previous attendant was in fault. Besides, the most scientific and experienced physician may sometimes err unavoidably. 1004 OONCLUSION. and you must never attempt to aggravate the consequences of his failure by adding to the patient's dissatisfaction. Conduct of this kind will cause the offender to be shunned, and sooner or later to feel that no success, and no wealth, can compensate for the absence of self-esteem or the good opinion of the enlightened and honorable men of his own pro- fession. Gentlemen, habitually engaged as you will be at the bed-side of the sick and the dying, you will have abundant opportunities of rightly esti- mating the insufficiency of mere worldly considerations. I think you will find, notwithstanding what is said to the contrary, that there is no class of society in which the true spirit of religion is more extensively diffused than among members of the medical profession. True, they shrink from an officious and public manifestation of it, and their habits of thought teach them to distinguish between trifling forms and essen- tial truths; but I know of no calling more practically engaged in acts of charity, in an abnegation of self, a desire to do to others what we wish others should do to us, and an endeavor, if occasion require it, to afford all those consolations which a pure Christianity can alone impart. This has ever been the conduct by which all the brightest and most eminent characters in our profession have been distinguished, and I ear- nestly pray that such may be yours. And now, gentlemen, I and my colleagues bid you farewell, trusting that whatever part you are destined to fulfil in the affairs of life as medical practitioners, you will ever labor under a deep sense of respon- sibility, that you will always act in sincerity and truth, and ever be governed by a high feeling of duty and of moral obligation. Let us hope that you will regard your past teachers as your future friends, and that in whatever part of the world, however distant, your lot may be cast, we shall still be united by a chain of good feeling and mutual es- teem, which, however it may be lengthened, can never be cut across. We desire that you will consider the reputation of this University as in some degree identified with your own, and whilst on the one hand you take care never to sully the degree she has this day conferred, on the other you will, by constant good conduct, and by well-directed endeavor, add fresh lustre to the reputation she holds among the academic institu tions of this great country. TABLE OF CASES. DISEASES OF THE NERVOUS SYSTEM. Case PAGg I. Acute hydrocephalus—Recovery . . . . . 36C II. Acute hydrocephalus iu a scrofulous child—Recovery . 861 III. Acute hydrocephalus—Phthisis pulmonalis—Death—Effusion into the lateral ventricles—Non-inflammatory softening of the cen- tral parts of the brain—Meningitis at the base of cranium— General tuberculosis ...... 362 IV. General acute meningitis supervening on pleuro-pneumonia . 367 V. Acute meningitis at the base of brain—Serous effusion into the ventricles, with white softening of cerebral substance—Phthisis 363 VI. Acute meningitis at the base of the brain—Effusion of serum into the lateral ventricles—Effete tubercle in the pons varolii and lungs ........ 369 VII. Chronic meningitis—Serous effusion into the ventricles—Tuber- cular mass in the left lobe of the cerebellum—Cretaceous tuber- cle in the lungs, with fibrous cicatrix .... 373 VIII. Chronic cerebral meningitis—Induration surrounded by softening of a portion of the left cerebral hemisphere . . . 374 IX. Acute cerebritis—Abscesses in the brain—Old tubercle in various organs—Chronic peritonitis . 376 X. 'Acute cerebritis—Abscesses in the brain—Pulmonary tubercle— Abscess in the kidney ...... 377 XI. Chronic cerebritis—Epileptiform convulsions—Hemiplegia of the right side—Loss of smell—Blindness of the left eye—Amyloid bodies in the brain . . . . . . . 380 XII. Chronic meningo-cerebritis—Sudden convulsions—Hemiplegia of left side—Softening of anterior lobe of right cerebral hemisphere —Adhesions of arachnoid ...... 382 XIII. Chronic cerebritis of the right hemisphere—Cancerous ulcer of the oesophagus and neighboring glands—Fatty heart . _. 384 XIV. Paralysis of the abducens occuh and auditory nerves—Exophthalmia —Tumor at the base of the cranium—Partial recovery . . 386 XV. Paralysis rapidly becoming general—Old apoplectic cyst in right corpus striatum—Softening of pons varolii—Clot obstructing basilar artery—Pneumonia of left lung .... 390 XVI. Apoplexy—Hemiplegia of left side—Convulsive attacks—Cardiac and renal disease—Old clot in the right cerebral hemisphere, with surrounding softening . . . . .392 XVII. Two sudden attacks of Apoplexy—Hemiplegia—Cardiac disease- Persistent albuminuria—Enlarged and diseased spleen—Cere- bral softening—Anasarca—Atheroma of arteries—Obstruction • of middle cerebral artery ...... 395 XVIII. Apoplexy, followed by hemiplegia of left side—Recovery . . 400 XIX. Apoplexy, followed by hemiplegia of left side—Recovery . . 400 XX. Palsy—Hemiplegia of the left side—Recovery- . . .401 XXI. Sudden Paralysis of face and left arm—Pneumonia—Bright's dis- ease—Recovery ....... 402 XXII. Apoplexy—Extravasation of blood into the left corpus striatum— Pneumonia—Arrested tubercle of lung . . . .403 XXIII. Apoplexy—Hemiplegia of left side—Hemorrhage into right cere- bral hemisphere—Diseased heart—Pneumonia . . . 404 XXIV. Apoplexy—Hemorrhage at the base of the brain in a boy aged 14 years ........ 405 XXV. Apoplexv, followed by delirium, and proving fatal in eight hours __Hemorrhage into the meninges of the brain . . . 405 1006 TABLE OF CASES. Case XXVI, XXVII XXVIII. XXIX. XXX. XXXI. XXXII. XXXIII. XXXIV. XXXV. XXXVI. XXXVII. XXXVIIl. XXXIX. XL. XLI. XLII. XLIII. XLIV. XLV. XLVI. XL VII. XLVIII. XLIX. Hemorrhage into the right crus cerebri—Meningitis at the base of the encephalon—Serous effusion into the lateral ventricles— Chronic phthisis—Vertigo—Paralysis—Spasms of the jaw— Delirium and coma ...... Apoplexy—Hemorrhage into right optic thalamus, causing hemi- plegia on left side—Progressive recovery—Two months after- wards, hemorrhage into pons varolii and membranes on right side—Death in seven hours ..... Five years before admission, hemiplegia, followed by recovery— Four months before admission, apoplexy, with convulsions and partial recovery—Pulmonary disease—Death by asphyxia— Chronic softening of right corpus striatum—More recent hem- orrhage into the pons varolii—Cardiac hypertrophy, with mitral constriction—Hemorrhage into the lungs Three attacks of apoplexy—The first dependent on hemorrhage into the right corpus striatum, in May 1861; the second on hemor- rhage into the left cerebral lobe and right optic thalamus, No- vember 1861; and the third on hemorrhage into the arachnoid cavity, March 1862—Atheroma of the blood-vessels—Hyper- trophy of heart—Chronic disease of lungs, liver, and kidneys . Cancer of the brain, spinal cord, liver, and bones . Chronic hydrocephalus—Paracentesis capitis^No benefit . Otorrhcea — Sudden lumbar and cervical pains — Convulsions— Spinal meningitis ....... Acute myelitis in the cervical portion of the cord—General pains resembling those of rheumatism—Fugitive paralysis in the arms and legs—Engorgement of the lungs—Death Slight paraplegia—Recovery . Paraplegia—Partial recovery . Paraplegia—Incurable .... Paraplegia—Chronic myelitis . Paraplegia—Tubercular caries of dorsal vertebrae—Myelitis—Pul monary tubercle ...... Paraplegia—Cancer of vertebra] bones — Softening of the cord , from pressure—Cancer of lung, liver, and lumbar glands— Ulceration of urinary bladder ..... Neuralgia of the suborbital nerve and subsequent irritation and paralysis of various nerves at the base of the cranium, from cancerous disease of the Dones—Catarrhal pneumonia . Partial amaurosis — Spectral illusions—Perversions of hearing, smell, and touch—Spinal irritation Delirium tremens—Recovery .... Delirium tremens with ocular spectra—Recovery Delirium tremens with convulsion and coma—Recovery Coma and death from excessive drinking—Opacity of arachnoid Subarachnoid effusion—Fluid blood Poisoning by opium—Recovery Poisoning by opium—Recovery Poisoning by hemlock—Death Poisoning by lead — Painter's colic—Lead paralysis—Pa covery ..... Paoh 408 411 412 414 421 424 427 428 430 431 431 432 434 438 441 445 455 455 ■ 456 cnnoid— 456 458 • 459 459 rtial re- 464 DISEASES OF THE DIGESTIVE SYSTEM. L. Tonsillitis ....... LI. Follicular pharyngitis ...... LII. Stricture of the oesophagus from epithelioma LIII. Epitbeliomatous ulceration of the oesophagus, communicating with the lung—Pneumonia terminating in gangrene . LIV. Carcinomatous stricture of oesophagus—Cancer of the liver—Pul monary emphysema and tubercle—Pneumonia . IV. Dyspepsia ....... LVI. Dyspepsia—Oxaluria ...... LVII. Dyspepsia—Hypochondriasis—Oxaluria LVIII. Dyspepsia—Vomiting of fermented matter containing sarcinae LIX. Dyspepsia—Vomiting of fermented matter containing sarcinas LX. Chronic ulcer of the stomach—Recovery 466 467 467 468 470 472 473 474 479 481 481 TABLE OF CASES. 1007 489 491 495 496 496 497 Case Page LXI. Chronic ulcer of the stomach—Cure ..... 482 LXII. Chronic ulceration and perforation of the stomach—Peritonitis— Limited pneumonia with gangrene—Abdominal abscess, simu- lating pleurisy—Death ...... 483 LXIII. Chronic ulceration iu the stomach—Perforation occasioned by a fall (?)—Recovery ....... 487 LXIV. Cancer of stomach, pancreas, and mesenteric glands—Cystic atrophy of right kidney . . . . . LXV. Colloid cancer with perforating ulcer of stomach—Peritonitis IAVI. Poisoning by oxalic acid—Recovery .... LXVII. Poisoning by sulphuric acid—Recovery LXVIII. Poisoning by corrosive sublimate—Recovery LXIX. Acute congestion of the liver—Hepatitis—Recovery LXX. Acute jaundice—Albuminuria—Recovery LXXI. Abscess of the liver, bursting into the right thoracic cavity, and into the retro-peritoneal cellular tissue—Pneumonia and gan- grene of right lung—Pneumo-thorax . . . .501 LXXII. Impaction of a gall-stone in common bile-duct—Atrophy of the substance of the liver—Jaundice—Death . . . 504 LXXIII. Jaundice—Compression of the ductus communis choledochus from a cancerous tumor, composed of epigastric and lumbar glands —Occlusion of cystic duct—Enlargement of gall-bladder—Can- cer of the pancreas—Biliary congestion of the liver—Cancerous exudation into various organs—Slight leucocythemia . . 506 LXXIV. Jaundice — Cancerous tumor of the pancreas, comprising the ductus communis choledochus—Dilatation of the gall-bladder, and passage of gall-stones into the gall-bladder—Cancer of the liver and kidneys ....... 509 LXXV. Enlargement of the liver—Ascites—Albuminuria—Recovery . 510 LXXVI. Fatty enlargement of the liver ..... 511 LXXVII. Cirrhosis with atrophy of the liver—Ascites . . . 514 LXXVIII. Cirrhosis with enlargement of liver—Hypertrophy of spleen— Slight leucocythemia — Jaundice — Constriction of arch and descending aorta ....... 514 LXXIX. Cancerous exudation into the liver—Cancerous ulceration of oeso- phagus—Simple stricture of pylorus—Profuse haematemesis— Aneurism of thoracic aorta, bursting into the left pleura . 518 LXXX. Hydatid cyst of the liver diagnosed by means of the microscope— Its puncture—Discharge of Echinococci—Recovery . . 522 LXXXI. Diarrhoea—Recovery ...... 524 LXXXII. Diarrhoea—Recovery ...... 524 LXXXIII. Acute dysentery—Recovery ...... 526 LXXXIV. Sub-acute dysentery—Recovery ..... 527 LXXXV. Chronic dysentery—Ascites and oedema of the legs—Leucocythemia —Cirrhosis of the liver—Cancer of the lung . . . 527 LXXXVI. Obstruction of the large intestine—Cancer of stomach, liver, peri- toneum generally, and mesenteric glands . . . 534 LXXXVII. Strangulation of the small intestine from inguinal hernia—Gan- grene, ulceration, and perforation of the intestine—Peritonitis . 535 LXXXVIII. Tape-worm treated by the ethereal extract of the male shield fern 542 LXXXIX Tape-worm expelled by the ethereal extract of the male shield fern.........543 XC. Tape-worm expelled by the same remedy . . . .543 XCI. Tape-worm expelled by kamala—Return of the parasite—Ultimate cure by means of the male shield fern .... 544 XCII. Acute peritonitis—Recovery . . . . . .545 XCIII. Acute peritonitis from bursting of Graafian vesicles into the peri- toneum—Pleurisy—Interlobular pneumonia . . .546 XCIV. Tubercular peritonitis with great deposit in parietal layer- Tubercle and hepatisation of lungs—Pleuritis—Adherent peri- cardium— Commencing fatty degeneration of heart — Biliary congestion and fatty degeneration of liver—Slight leucocy- themia . • ■ •.-',,• • • 549 XCV. Cancer of various abdominal organs and of the lungs, producing symptoms of peritonitis . . . . . .551 XCVI Cancerous peritonitis — Ascites and hydrothorax — Paracentesis J ' abdominis—Arrested phthisis pulmonalis . . .554 1008 TABLE OF CASES. DISEASES OF THE CIRCULATORY SYSTEM. Case Page XCVII. Acute pericarditis—Recovery ..... 559 XCVIII. Pericarditis and endocarditis—Hydropericardium . . . 560 XCIX. Acute pericarditis followed by acute double pneumonia—Reco- very—Aortic incompetence—Subsequent articular rheumatism —Sudden death—Adherent pericardium—Fatty enlarged heart Thickening of aortic valves ..... 561 C. Acute pericarditis supervening on phthisis .... 564 CI. Ascites—Anasarca—Adherent pericardium with fatty atrophied heart—Congested liver ...... 566 CII. Rheumatic pericarditis ...... 568 CHI. Rupture of aortic valves ...... 576 CIV. Incompetency of aortic valves—Dilated hypertrophy of left ven- tricle—Dilatation of ascending portion of aortic arch—Chronic arteritis with aneurismal pouches . . . . 577 CV. Incompetency of aortic valves—Hypertrophy of left ventricle and auricle — Obstruction and incompetency of mitral valve— pneumonia ........ 577 CVI. Incompetency of mitral valve ..... 571) CVTI. Incompetency of mitral valve—Pulmonary hemorrhage—Hydro- thorax ........ 579 CVIII. Mitral incompetency—Hypertrophy of left ventricle—Attack of acute rheumatism, followed by aortic incompetency . . 580 CIX. Mitral incompetency—Hypertrophy of left ventricle — Aortic incompetency and obstruction—Angina .... 581 CX. Incompetency of the aortic valves with musical murmur—Hy- pertrophy with dilatation of left ventricle—Pneumonia—Pul- monary hemorrhage ...... 583 CXI. Mitral incompetency—Hypertrophy of left ventricle—Ditetation and disease of arch of aorta—Aortic incompetency . . 584 CXII. Great constriction of mitral orifice—Dyspnoea, palpitation, cough,, and haemoptysis—Loud prae-systolic (or diastolic-mitral) mur- mur—Death following abortion—Enlargement of the two auri- cles and right ventricle—Atrophy of left ventricular walls . 585 CXIII. Constriction of mitral and tricuspid orifices—Aortic incompetency —Anasarca — Hydrothorax — Collapse of left lung—Bright's disease of kidney . . . . . . . 587 CXIV. Constriction of mitral and tricuspid orifices—(Edema—Hemor- rhage into the lungs ...... 588 CXV. Soft adherant polypus, causing incompetency of the mitral orifice —Anasarca .... . . . . . 590 CXVI. Enlarged foramen ovale—Phthisis . 592 CXVII. Aneurism of aortic valve, coincident with a systolic murmur at the base of the heart—Pneumonia-meningitis . . . 601 CXVIII. Aneurism of the ascending arch of the aorta—Incompetency of aortic valves—Hypertrophy of left ventricle . . ' . 602 CXIX. Aneurism of ascending aorta immediately above the aortic valves —Incompetency of aortic and mitral valves—Hypertrophy of left ventricle—Waxy kidneys—Pulmonary hemorrhage—Ana- sarca . . . . . . . . 603 CXX. Aneurism of ascending arch of aorta—Chronic pericarditis—Dis- ease of aortic valves—Great hypertrophy of heart—Anasarca . 605 CXXI. Large aneurism of the ascending arch of the aorta, causing ab- sorption of a portion of the third rib, and bursting into the pericardium — Chronic pericarditis — Incompetency of aortic valves—Hypertrophy of left ventricle' .... 606 CXXII. Varicose aneurism of the ascending aorta communicating with the pulmonary artery—Jaundice and nutmeg liver . . . 60S CXXIII. Aneurism of the arteria innominata ..... 613 CXXIV. Aneurism of transverse aortic arch—Chronic pericarditis with effusion—Tubercular lungs—Anasarca—Former popliteal aneu- rism cured by compression ..... 616 CXXV. Aneurism of lower portion of the thoracic aorta, pressing on the thoracic duct—Aneurism of abdominal aorta—Chronic ulcer of stomach—Chronic tubercular abscesses of liver and right kid- ney—Liver and left kidney waxy—Leucocythemia . . 618 CXXVI. Aneurism of the superior mesenteric artery and aorta—Obscure aneurism of descending thoracic aorta— Treatment by the method of Valsalva—Pleuritis—Caries of the vertebrae, soft- TABLE OE CASES. 1009 CA» Page ening of spinal cord and paraplegia—Sudden death by poison- pyyvtt Bi,,1Dug -Wlth the tincture of aconite.....620 lAA v u- Phlebitis of the left iliac vein, supervening on cancer of the sto- r„ mach and oesophagus......634 UAA v ill. Angio-leucitis, supervening on rupia—Recovery . . .635 DISEASES OF THE RESPIRATORY SYSTEM. C^,?.|^- Acute laryngitis—Treated by topical applications—Recovery . 638 pVVvt' V ?niC lal7ngitis—Topical applications—Recovery . . 639 UAAA1. Acute oedema of the glottis—Chronic pharyngitis and laryngitis— Sudden death . . . . . . .642 CXXXII. Acute laryngitis supervening on ascites, and cirrhosis of liver—Sud- r-YWTTT den.d,eath from asphyxia......644 ^ft^'U- £hr°mc. laryngitis and pharyngitis—Tracheotomy—Recovery . 646 VAAAl V. Pertussis—Violent paroxysms—Bronchitis—Collapse of the lungs —Recovery ........ 649 CXXXV. Acute bronchitis . . . . ! 651 CXXXVX Chronic bronchitis—Acute peritonitis—Collapse of the lung .' 653 nvb^rr?T ^ronic bronchitis—Emphysema—Acute laryngitis . . 654 LAAAVIII. Chrome bronchitis—Emphysema—Injection of the bronchi with a __.VVT_ solution of the nitrate of silver ..... 657 CXXXIX. Acute pleurisy—Recovery ••.... 660 n*v? t' Acute pleurisy without functional symptoms—Rapid recovery . 661 CXLI. Chronic pleurisy on both sides—Bronchitis . . . .663 CXLII. Empyema, with fistulous openings between the lung and pleural v cavity, and between the pleural cavity and external surface . 667 CXLIII. Chronic pleuritis and pneumo-thorax, without symptoms—Articu- v lar rheumatism—Pericarditis—Recovery . . .669 CXLIV. Empyema, following chronic phthisis — Paracentesis thoracis— Pneumo-thorax—Singular mode of death from enormous dis- tention of the stomach and emphysema of its coats—Tubercular pleuritis—Adherent pericardium—Waxy spleen—Tubercle in the kidneys ........ 671 CXLV. Chronic pleurisy, with fluid in the left chest, forcing the heart into the right thoracic cavity—Recovery .... 677 CXLVI. A similar case—No improvement ..... 677 CXLVII. Pneumonia on right side and slight pleuritis—Recovery . . 678 CXLVIII. Double pneumonia, with urgent symptoms, and full strong pulse —Pleuritis on left side—Recovery in nine days . . 679 CXLIX. Double pneumonia—Great dyspnoea—No bleeding—Local warmth and stimulants—Rapid recovery ..... 681 CL. Pneumonia on the right side—Early bleeding—Slow recovery . 682 CLI. Double pneumonia—Treatment by mercury, which caused profuse salivation before admission—Prolonged recovery . . 684 CLII. Pneumonia—ushered in by violent vomiting and gastric pain—Re- covery in five days ....... 685 CLIII. Bronchitis and pulmonary congestion, from morbus cordis, resem- bling pneumonia, but no absence of chlorides in the urine . 688 CLIV. Chronic pneumonia of upper third of right lung — Gangrenous abscess—Recovery ....... 713 CLV. Chronic pneumonia of both lungs, with ulceration—Death—Great condensation, with cavities and pigmentary deposits in the lungs —Chronic tubercle in various organs—Disease of both supra- renal capsules, without bronzing of the skin . . . 714 CLVI. Gangrene of the lungs—Dysentery . . . . .716 CLVII. Gangrenous abscess of the right lung, caused by swallowing a piece of chicken bone four and a half years previously . . 718 CLVIII. Phthisis pulmonalis in its last stage, with incompetency of the aortic valves—Cod-liver oil and nutrients—Complete recovery . 722 CLIX. Phthisis pulmonalis—Amendment from treatment and disappear- ance of symptoms—Their subsequent return—Death . . 725 CLX. Phthisis pulmonalis—Large vomica on left side—Cirrhosis of lung —Caries of left wrist-joint—Scrofulous nephritis . . 727 CLXI. Chronic phthisis—Enlarged liver — Albuminuria—Large excava- tion in left lung—Cicatrices and induration of right lung__ Waxy li^er and kidneys—Tubercular ulceration of intestine!. . 731 64 1010 TABLE OF CASES. Case Pag« CLXII. Advanced phthisis—Restoration to health—Death many years afterwards from delirium tremens—On dissection, a cicatrix, three inches long, in apex of right lung, and cretaceous con- cretions, with puckering at the summit of left lung . . 739 CLXIIL Cancer of the lung, thyroid body, and lymphatic glands of the neck—Bronchitis—Leucocythemia .... 754 CLXIV. Carbonaceous lungs with black expectoration . . . 756 CLXV. Carbonaceous lungs with black expectoration in a female . . 757 DISEASES OF THE GENITO-URINARY SYSTEM. CLXVI. Ovarian dropsy—Frequent paracentesis—Excision of both ovaries —Strangulation of the intestine—Phlebitis—Death from ileus the seventieth day after the operation .... 763 CLXVII. Ovarian dropsy—Spontaneous ulcerative opening of the cyst into the bladder, and evacuation of its contents—Recovery . . 770 CLXVIII. Ovarian dropsy which gradually emptied itself spontaneously by opening through the Fallopian tube—Singular attempt at im- position of pigs' bladders, for cystic formations in the uterus . 772 CLXIX. Ovarian dropsy—Perforation of the descending colon from without inwards—Death from ichorhasmia and persistent diarrhoea . 774 CLXX. Acute nephro-pyelitis—Recovery ..... 782 CLXXI. Subacute nephritis, with great anasarca—Recovery—Acute nephri- tis of left kidney—Recovery ..... 784 CLXXII. Acute desquamative nephritis, proving rapidly fatal from diminish- ed flow of urine, general anasarca, and oedema of the lungs . 785 CLXXIII. Acute desquamative and hemorrhagic nephritis— Hydrothorax— Collapse of the right lung—Pulmonary cedema and bronchitis, with symptoms of pneumonia ..... 787 CLXXIV. Acute nephritis—Chronic pneumonia—(Edema of the lung and anasarca proving fatal—Perforating ulcer of the duodenum, without symptoms ....... 7-89 CLXXV. Nephritis followed by the formation of a large abscess in the right kidney, opening into the lumbar cellular tissue—Ulceration of ureter and bladder—Thickening of mitral and tricuspid valves —Partial atrophy of lungs, with and without induration—Par- tial oedema ....... 791 CLXXVI. Scrofulous nephritis and abscesses in the kidneys—Extensive deposition of tubercle in the lungs and intestines . . 793 CLXXVII. Calculous nephritis and gangrenous abscess of the right kidney —Waxy liver—Recto-vesical fistula .... 795 CLXXVIII. Chronic pyelitis, and cystic kidneys—Dilatation of ureters—Fun- goid ulceration of urinary bladder .... 797 CLXXIX. Albuminuria—General anasarca—(Edema of lung—Recovery . £01 CLXXX. Albuminuria—(Edema of both feet and legs, left arm and hand— Recovery ........ 802 CLXXXI. Albuminuria—(Edema—Ascites and general anasarca—Coma and convulsions—Recovery ...... 804 CLXXXII. Third attack of general anasarca with albuminuria—Enormous dropsical distention of the abdomen, scrotum, and inferior ex- tremities—Complete recovery under the action of supertartrate of potash ... . . . . . i 05 CLXXXHI. Second attack of albuminuria with anasarca—Dismissed relieved . 807 CLXXXIV. Second attack of albuminuria after an interval of twenty-nine years, with anasarca—Bronchitis—Dismissed relieved . . 803 CLXXXV. Third attack of albuminuria with anasarca—Dismissed relieved . 0.) CLXXXVI. Albuminuria, with general anasarca, terminating fatally—Waxy kidneys, spleen, and liver, with extensive deposition of tubercle 8i0 CLXXXVH. Albuminuria—Excessive amount of urine—Phthisis pulmonalis— Waxy liver, kidneys, and spleen ..... 8il CLXXXVIII. Albuminuria with great increase of urine—Waxy kidneys, spleen, and liver ........ 813 CLXXXIX. Albuminuria—Syphilitic ulcerations of throat—Enlarged spleeu and liver — Leucocythemia — Waxy degeneration of kidneys, liver, and spleen* ....... 814 CXC. Enlarged liver and spleen—Leucocythemia, and fibrinosis of the blood—Albuminuria—Waxy kidneys . , . . . 815 TABLE OF CASES. 1011 Case CXCI. Albuminuria, with phthisis pulmonalis, terminating fatally—Ex- tensive deposition of tubercle and colliquative diarrhoea—Atro- phied fatty kidney—Ulcerated intestines .... Pagb 817 DISEASES OF THE INTEGUMENTARY SYSTEM. CXCII. Favus of the scalp in an adult—Incurable . . . .847 CXCIII. Favus of the scalp of three years'standing—Cured . . . 848 CXCIV. Favus caught in the ward from Case CXCII.—Cured . .848 CXC V. Favus of the scalp of four years' standing, cured by a sulphurous acid lotion . . . . . . . . 849 CXCVI. Limited favus of the cheek, cured by cauterisation' with nitrate of silver ........849 CXCVII. Parasitic pityriasis—Incurable ..... 864 CXCVIII. Pityriasis versicolor—with the microsporon furfur of Eichstadt— Cured by pitch ointment ...... 865 DISEASES OF THE BLOOD. CXCIX. Leucocythemia discovered after death—Hypertrophy of the spleen, liver, and lymphatic glands—Absence of phlebitis and of puru lent collections in any part of the body CC. Leucocythemia detected during life—Hypertrophy of the spleen— Ascites ........ CCI. Commencing leucocythemia determined during life — Enlarged spleen and liver—Ascites ..... CCII. Eczema of the trunk and limbs—Enlarged lymphatic glands Leucocythemia, which sensibly diminished . '. CCIII. Chlorosis and anaemia—Cured . CCIV. Acute articular rheumatism—Multiple abscesses in the joints, in the muscles, within the cranium, &c. CCV. Diabetes mellitus ...... CCVI. Diabetes mellitus—Phthisis pulmonalis—Death CCVII. Diabetes mellitus—Improvement from the use of sugar CCVIII. Diabetes mellitus, treated with sugar—Great improvement for time, followed by cataract, phthisis, and death . CCIX. Diabetes—Treatment by sugar—Phthisis CCX. Diabetes—Treated in various ways . CCXI. to CCXIIL Cases of diabetes tabulated CCXIV. to CCXVII. Cases of febricula CCXVIII. Relapsing fever CCXIX. Typhoid fever—Convalescence on the forty-second day CCXX. Typhoid fever—Fatal on the twenty-fifth day CCXXI. Typhoid fever—Fatal from perforating ulcer of the intestine CCXXIL Typhus fever, with cerebral complication—Fatal . CCXXIII. Typhus fever—Terminating on the fourteenth day . CCXXIV. Typhus fever—Terminating on the twenty-third day CCXXV. Typhus fever, with petechia?—Convalescent sixteenth day . CCXXVI. Typhus fever—Convalescent the twenty-fourth day . CCXXVII. Typhus fever—Convalescent the fourteenth day CCXXVIIL Typhus fever—Convalescent the fourteenth day CCXXIX. Typhus fever, complicated with bronchitis and collapsed lung Fatal on the twelfth day ..... CCXXX. Typhus fever—Convalescent on the twelfth day CCXXXI. Typhus fever—Convalescent on the twenty-first day CCXXXII. Typhus fever—Convalescent on the twenty-second day CCXXXIII. Typhoid succeeded by typhus fever . . . CCXXXIV Typhoid fever—Convalescent on the twenty-nrst day CCXXXV.' to CCL. Typhoid and typhus fevers, 1862-*59 CCLI. Infantile remittent fever . . CCLII. Tertian intermittent cured by quinine CCLIII. Scarlatina with angina . CCLIV. Scarlatina with violent delirium CCLV. Scarlatina treated with moist warmth CCLVI and CCLVII. Scarlatina—The skin kept cool and dry CCLVIII* Scarlatina with diminished urine and coma , 873 878 879 900 902 907 908 912 912 913 914 915 921 923 924 925 926 927 928 928 929 929 930 930 930 931 931 931 937 938 940 949 951 954 954 956 958 959 1012 TABLE OP CASES. Case CCLIX. CCLXII. CCLXIII. CCLXIV. CCLXV. CCLXVI. CCLXVII. CCLXVIII. CCLXIX. CCLXX. CCLXXL CCLXXII. CCLXXVI. CCLXXX. CCLXXXI. CCLXXXII. CCLXXXIH. CCLXXXV. CCLXXXVI. CCLXXXVII. to CCLXI. Scarlatina treated with the wet sheet . Erysipelas—Recovery on the eleventh day Erysipelas in an intemperate man—Slow recovery Variola—Severe confluent case Variola discreta ..... Variola—Ectrotic treatment.... Diphtheria—Recovery .... Diphtheria complicated with small-pox—Death—Diphtheritic membrane covering the mucous membrane of the pharynx, epiglottis, larynx, trachea, and right bronchus—pulmonary apoplexy . . . . . . . . Syphilitic ulceration of the face ..... Syphilitic laryngitis ....... Syphilitic rupia, followed by keloid growths on the cicatrices— Syphilitic psoriasis ...... to CCLXXV. Treatment of acute rheumatism by nitrate of potash to CCLXXIX. Treatment of rheumatism by lemon-juice . Diaphragmatic rheumatism ...... Rheumatic iritis, following acute rheumatism—Recovery. Chronic gout with tophaceous deposits in all the joints . and CCLXXXIV. Scorbutus . . . Sudden polydipsia—Incurable ..... Polydipsia the last two months of pregnancy—disappearing after delivery ........ Great obesity—Fatty degeneration of heart and muscular system generally—Of liver and kidneys—Hypertrophy and dilatation of heart ...... Paob 960 961 961 692 963 965 969 971 972 973 984 988 989 990 991 993 995 996 997 i:n"dex. Abdomen, auscultation of, 73 ; inspection of, 37; post-mortem examination of, 32; view of the viscera in, 34 Abscess, pathology of, 166; resolution of, 173; in the brain, cases of, 376; in the abdomen, 483; in the liver, cases of, 501, 618; in the lung, cases of, 713; in the kidney, cases of, 791, 793, 795 Acarus scabiei, description and treatment of, 842 Achorion Schoenleinii, history of the, 850. See Favus Acne, diagnosis of, 832; treatment of, 839 Aconite, case of poisoning by, 620, 628; symp- toms of, 629 ; influence of on the heart, 338, 453 Address to graduates in medicine in 1849, 999 Adenoma, 206 Adhesions between serous surfaces, pathology of, 165 ; of arachnoid, case of, 374; of peritoneum, case of, 549; of pericardium, 566; of pleura, 665 Albumen and oil considered as types of nutritive substances, 126 Albumen, detection of in urine, 110; in solution, 246 ; membranous, 247 ; fibroid, 247; celloid, 248; molecular, 249 Albuminous degeneration, 246 ; concretions, 273 Albuminuria, persistent, cases of, 801; pathology of, 819; diagnosis of, 823 ; treatment of, 825 Aliment, 125; conditions regulating, 125. See Food. Alison, Dr., his views as to blood-letting in in- flammations, 302; Dr. Scott, his stetho-gonio- meter, 48; his differential stethoscope, 64; his hydrophone, 65 Alkaline lotions in skin diseases, 837 Amaurosis, case of partial, 445 Ammonia, urate of, microscopic appearance of, 104 Amphoric resonance in cases, 669, 671 Amyloid and amylaceous concretions, 282; in the auditory nerve, 283; in the pancreas, 283 ; in the brain, 380 Amyloid degeneration, 250 Andral's opinion of the expression " inflamma- tion," 160 Anaemia, case of, 900; pathology and treatment of, 901 Aneurism, nature and varieties of, 216; cases of in aortic valve, 601; in arch of aorta, 601; varicose, communicating with pulmonary ar- tery, 608; of arteria innominata, 613 ; of tho- racic aorta, 618 ; of superior mesenteric artery, 620; general diagnosis of, 630; pathology of, 633; feeatment of, 633; Valsalva's treatment of, 662 Angina pectoris, 600; case of, 581 Angionoma, 216 Angio-leucitis, 635 Animal heat, 135 Anorexia in phthisis, treatment ot, 750 Antimonials, treatment of pneumonia by large doses of, 694, 695 til_. . . . Anxiety and despondency in phthisis, treatment ' of, 753 Aorta, disease of, 584; cases of aneurism of, 602. See Aneurism Aortic valves, disease of, 583; aneurism of, 601; rupture of, 576 Apoplexy, definition of, 353, 448 ; cases of, 390 ; predisposing cause of, 416 ; histology of, 417 ; diagnosis of, 418; pathology of, 397; treatment of, 420 Appetite, treatment for loss of in phthisis, 750 Arteries, cerebral disease from obstruction of, 390; pathology of, 397; fatty degeneration of, 256; mineral degeneration of, 269 Arteritis, chronic, case of, 577 Ascites, microscopic appearances in fluid of, 103 ; from enlargement of liver, 510, 566; from peritonitis, 550; from abdominal cancer, 553; from cirrhosis, 527; from ovarian disease, 776 ; treatment of, 517 Asthma, causes of, 655; treatment of, 657; injec- tions of the bronchi in, 697 Assimilation of the food, 128; effects of bad assimilation, 136 Atelectasis, 654 Atheroma, cystic, 199 ; of blood-vessels, 256 Atrophy of face, remarkable case of, 155 Auscultation, general rules for practice of, 63 ; of abdomen, 73; of circulatory organs, special rules for, 70; Bounds elicited in health and disease, 71; modifications of healthy sounds, 72 ; new or abnormal sounds, 73 ; of pulmon- ary organs, special rules for, 66 ; sounds elici- ted by, 66 ; alterations of natural sounds, 67; new or abnormal sounds, 68; of the large vessels, 74; relative value of sounds in, 66 ; of aneurisms, 631; rules derived from in diseases of the circulatory system, 557; rules derived from in diseases of the respiratory system, 636 Bael, Indian, use of in dysentery, 529 Bathing, therapeutic uses of, 328 Bile, detection of, in urine, 110; bile acids, 111 Biliary calculi, 274 Bladder, percussion of, 62; urinary calculi in, 276; opening of ovarian cyst into, 770; fun- goid ulceration of, 797 Blood, appearance of, under the microscope, 91; in thickened blood, 92 ; in haematocele, 92 ; in leucocythemia, 93, 882, 887; appearance of, in a case of cholera, 92; formation of, from alimentary matters, and the changes it under- goes in the lungs, 128 ; determination of, 130; chemical alterations in disease of the, 133 ; formation of, 128 ; reabsorption of transformed tissues into the, 131 ; circulation of, 130; pas- sage of fluid from, to be transformed into the tissues, 130; chemical constitution of healthy, 132 ; function of the, 132; morbid conditions of the, 132 ; chemical alterations of, in disease, 133; diseases of the, 136, 882, 887; causes of disease in the, 136; principle of treatment of, 137; post-mortem examination of, 32; micro- scopic examination of, 91; mixture of dus with 896 F ' Blood corpuscles, relation between the colorless and colored, 882; origin of the, 884 ; ultimate 1014 INDEX. destination of the, 890; structural alterations in, 93 Blood-forming glands, structure of, 128, 881; functions of, 128 Blood-letting, diminished employment of in treatment of acute inflammations, 302; former reasons for, erroneous, 306; local, observations of, Dr. John Struthers on, 310; can the ma- teries morbi in the blood be diminished by ? 306 ; can it diminish the flow of blood to the inflamed part? 308; can it diminish the amount of blood in an inflamed part ? 309; should it be indicated by the character of the pulse ? 312; in acute pneumonia, 316, 692; useful as a palliative, 313; and in over-disten- sion of the right side of the heart, venous congestion, engorgement, etc., 317; in func- tional nervous disorders, 454 Blood-vessels, changes in previous to inflamma- tion, 156; new formation of, 219; fatty degen- eration of, 256; mineral degeneration of, 269 Bone, fatty degeneration of, 259; formation of new, 227 ; morbid growths of, 225 Borborygmi, 73 Bowditch, Dr. H., on thoracentesis, 675 Brain, distinction between pressure on and com- pression of, 149; proper functions of the, 139 ; effects of removal of, 140; amyloid concre- tions in the, 282, 381 ; softenings of the, 353; abscess in the, 376; chronic inflammation of the, 380; obstruction of arteries in the, 390; hemorrhage in the, 400 ; cases of tubercle in the, 309, 373; cancer of the, 421; dropsy of the, 424; acute inflammation of the, 376; functional disorders of the, 447 Breathing, bronchial'Or tubular, 68 Bright's disease, 801; casts of uriniferous tubes in, 105,824; cases of, 801; pathology of, 819; forms of, 819 ; diagnosis of, 823; treatment of, 825 Bronchi, injections of the, in pulmonary diseases, 658 Bronchitis, acute cases of, 651; nature and treatment of, 652; chronic, cases of, 653; causes of, 655; treatment of, 656 Bronchophony, 67 Bronzing of the skin, Dr. Addison on, 264 Bruit de diable, 601 Bulla, definition of, 828 Calculi, biliary, 274; urinary, 275 ; renal, 275; vesical, 276; prostatic, 278; intestinal, 280 Callosities, 210 ; cause of, 210 Cancer, general description of, 229; scirrhous, 229; encephalomatous, 230; cells in simple and compound, 230; reticulare of Miiller, 230 ; colloid, 232; chimney-sweeps', 213; villous, 215; of the brain, 421; of the liver, 518; of the lung, 754; of the skin, 109; of the oesopha- gus, 470 ; of the stomach, 489, 534; of mesen- teric glands, 534; of abdominal organs simu- lating peritonitis, 551; of the peritoneum, 554; of vertebral bones, 437 ; of cranial bones, 441 Cancerous, growths, 229—(see Cancer); cyst of the liver, 522; peritonitis, 554 Cancrum oris, 171 Canman's stethoscope, 64 Cantharides, action of, 453 Capillaries, changes which take place in, pre- ceding inflammation, 156; contraction of the, note, 156; new formation of, 219 Carbonaceous lungs, 756; morbid anatomy and pathology of, 759; treatment of, 762 Carcinoma, 229. See Cancer Cardiac sounds, 70; diseases, rules for the diag- nosis of, 557 Caries, scrofulous, 436; cancerous, 437 ; from pressure of aneurism, 620 Cartilage, morbid growths of, 220; ulceration of, 223 ; fatty degeneration of, 259 Cartilages, loose, 194 Cartilaginous growths, 220 ; forms and structure of, 221; in articulations, 223 Cases, method of taking, 30 Casts of the tubuli uriniferi, varieties of in Bright's disease, 105, 824 Catalepsy, definition of, 449 Cell therapeutics, 307; theories of organisation, 115; theory of Schleiden and Schwann, 161; of Goodsir, 117 ; of Huxley, 117 ; of the author, 118; change of type theory, fallacy of, 299 Cells, importance of in practice, 20 ; fatty dege- neration of, 253; cell fibres, 189; fusiform, 189 ; plastic or pyoid, 165 ; granule, 167; fibre, 168, 189 ; of cancer, 229 ; development of morbid growths by, 235 ; pigment, 266, 267 ; transfor- mation of exudation by, in pneumonia, 690; in pericarditis, 175; in pleurisy, 165; on mucous membranes, 166; in the brain, 167; in healing granulations, 168; enlargement of, in pregnant uterus, 189; atrophy of, after delivery, 256 ; in malacosteon, 259 Cephalalgia, treatment of, 453 Cerebellum, structure and functions of, 142; effects of removal of, 143; disease of, 373 Cerebral and spinal softenings, pathology of, 353; origins and varieties of, 354; necessity for microscopic examination of, 358; cases of, 359, 380 Cerebral disease from obstruction of arteries, cases of, 390 ; pathology of, 397 Cerebral disorders, classification of functional, 447 Cerebral hemorrhage, cases of, 400; predisposing cause of, 416 ; microscopic appearances of, 417; diagnosis of, 418; treatment of, 420 Cerebral meningitis, cases of, 367 ; seat of, 370 ; microscopic appearances, 371; diagnosis of, 371; treatment of, 371; pathology of, 372 Cerebritis, acute, cases of, 376 ; chronic, cases of, 380 ; pathology of, 387 Cerebro-spinal disorders, classification of func- tional, 449 Cerebrum, structure and functions of, 139; effects of removal of, 110 Chest, inspection of, 36; mensuration of, 45; motions of during respiration, 37 ; post-mor- tem examination of, 31; view of viscera in, 34; percussion of, 54; auscultation of, 66 Chicken-pox, identical with small-pox, 967 Chlorides in urine, detection of, 112; absence of in pneumonia, 686 Chloroform not an anaesthetic, 452 ; inferior to cold as a true anaesthetic, 454 Chlorosis anaemia, cases of, 900 Cholera, microscopic appearance of blood in a case of, 92 Cholesteatoma, 202 Chorea, definition of, 448 Chyle, formation of, 128 ; of a dog, 743; of a cat, Chylification, 128 Cicatrisation, process of, 190 Cicatrix, structure of, 190 Circulation, 129; static force of the heart and arteries in, 130 Circulatory system, examination of, 26 ; action of medicines on the, 339; diseases of the, 557 ; rules for diagnosis of, 557 Circulatory organs, auscultation of, 70 ; sounds elicited by, in health and disease, 71; modifi- cations of healthy sounds of, 72 ; new or abnor- mal sounds in, 73 Cirrhosis of liver, cases of, 514; pathology of, 516; treatment of, 517 Clinical course, mode of conducting, 6; micro- scope of Dr. Beale, 80 Climate, therapeutic uses of, 325; influenc of in phthisis, 746; in producing fatty liver, 512 Clothing, therapeutic uses of, 327 Cod-liver oil in tuberculosis, 184; as a nutrient, 321; as increasing molecular elements, 336; introduced as a remedy for phthisis by the author, 744; mode of action, 745 ; in favus, 864 INDEX. 1015 Colchicum in scarlatina, 959 Cold, therapeutic uses of, 326 ; action of on the nervous system, 454 ; in inflammation, 176; in cephalalgia, 327 ; in fever, 946 Collapse of lung, 653 College of Physicians of Edinburgh, its sale of licenses, 17 Collier's lung, 756 ; pathology and treatment of, 758 Colloid cancer, 232 Colostrum of human, female, 90 Complemental nutrition, 135 Compression and pressure, distinction between, 149 Concretions, 272 ; albuminous, 273 ; fatty, 273 ; biliary, 271; pigmentary, 274 ; mineral, 275; urinary, 275 ; renal, 276; vesical, 276; prosta- tic, 278; hairy, 279 ; vegetable fibrous, 280; intestinal, 283 ; amyloid and amylaceous, 282 Condylomata, 212 Congelation a true anaesthetic, 454 Congestion preceding inflammation, 155; of the right side of-the heart, bleeding useful in, 317, 711 Congestive disorders of the nervous system, 450 Conium. See Hemlock Constipation, causes and treatment of, 525 Contagion, definition of, 953 Contractility defined, 148 Convulsion, definition of, 353, 448 Cord, spinal, cases of structural diseases of the, 427 ; pathology of, 438; functions of the, 144; functional disorders of the, 448 Corns, 210; causes of, 210 Corpuscles of the blood, 91; in thickened blood, hematocele, and cholera, 92; in leucocythemia, 93, 871; relation between the colored and colorless, 882; origin of the, 884; ultimate destination of the, 8lJ0 Corpuscles, pus, appearance of in healthy pus, 94 ; in scrofulous pus, 94 Corpuscles, salivary, 88; tubercle, 95, 179 Corrosive sublimate, poisoning by, 496 Coryza, nature and treatment of, 652 Cough and expectoration in phthisis, treatment of, 749 Countenance, inspection of the, 36 Cracked-pot sound, 56 Cranium, amount of fluids within the, 148; views of Drs. Hunro, Abercrombie, and Wat- son, 148; experiments of Donders and Kellie, 149; observations of Dr. Burrows, 150; obser- vations of Dr. John E-eid, 151 Curative action of remedies, 335 Cutaneous eruptions, microscopic examination of, 107 ; classification of, 828 ; diagnosis of, 831; treatment of, 836 ; on the scalp, 835 Cvstie dnct, occlusion of, 506 Cvstic growths, 199 ; simple, 199; compound, "200; contents of, 200; hygromatous, 200; col- loid, 201; melicerous, 202 ; cholesteatomatous, 202 ; atheromatous, 203; hairy, 203 ; with teeth, 203 ; osseous, 204; cancerous, remark- able case of, 518 Cystine, microscopic appearance ot, loo Cystoma, 199 Debility in phthisis, treatment of, 753 Degeneration, albuminous, 246; general patho- loW and treatment of the, 252 ; colloid, 2ol, fibroid, of Handfield Jones, 247 Degeneration, fatty, 252 ; of cells,,253; of mus- cle, 254 ; of Wood-vessels, 256; of the placenta, 25S ; of cartilage, 259; of bone, 259; of the exudations, 260 ; of morbid growths, 261, ot the heart, 598; general pathology and treat- DeTen^tion, mineral, 269; of blood-vessels, 269 ; of the exudations, 271; of nervous text- ure, 2") ; of morbid growths, 272 Degeneration, pigmentary, 262 : general patho- logy and treatment of, 2 37 Degeneration, waxy, 219 Degenerations of texture, morbid, 245 Delirium tremens, cases of, 455 ; pathology and treatment of, 457 Dermatophyta, diagnosis of, 833, 835. See Pavus Dermatozoa, 853 Despondency and anxiety in phthisis, treatment of, 753 Determination of blood, theory refuted, 308 Diabetes Mellitus, cases of, 907 ; theories regard- ing the nature and treatment of, 909 Diagnosis, effects of advanced knowledge of, 287 Diagnosis, microscopic, of saliva, 88; milk, 90; blood, 92 ; pus, 93 ; sputum, 94; vomited mat- ters, 97 ; faeces, 99 ; uterine and vaginal dis- charges, 100; mucus, 102 ; dropsical fluids, 103; urine, 103; cutaneous eruptions and ulcers, 107 ; the knowledge derived from an improved, 297 Diagnosis, general, of cardiac diseases, rules for the, 557; of thoracic aneurisms, 630; of abdominal aneurisms, 633; of pulmonary diseases, rules for, 637 ; of skin diseases, 831; of continued fevers, 931 Diarrhcea, cases of, 524; varieties and causes of, 525 ; pathology of, 530 ; treatment of, 525 ; treatment of in children, 533; treatment of in phthisis, 751 Diastaltic or reflex movements, 147 ; classifica- tion of disorders, 451 Diet, irregularity in, the most common cause of disease, 126 ; causing scurvy, 993 Dietetica, 320 Digestion, in the stomach and intestines, 127 ; kinds of, 131; disorders of, 472; pathology and treatment of derangements of, 475 Digestive system, examination of, 26; action oi medicines on the, 341; diseases of the, 466 Diphtheria, 968 Discharges, uterine and vaginal, microscopic examination of, 100 Disease, definition of, 114; natural progress of, 295 ; Bright's, cases of, 801; cerebral, from obstruction of arteries, 390; general laws of nutrition in, 124; general laws of innervation in, 137 ; irregularity in diet the most common cause of, 126; importance of a knowledge ol the causes of, 284 ; cause of recent changes in the treatment of, 284 ; of nutrition, 136 Diseases of the nervous system, 352; of the diges- tive system, 466 ; of the circulatory system, 547 ; of the respiratory system, 637 ; of the genito-urinary system, 763; of the integumen- tary system, 827 ; of the blood, 867 Drainage, as a cause of fevers, 943 Drinks, therapeutic uses of, 322. Dropsical fluids, microscopic examination of, 103 Dropsy, 246 ; general, 566, 784, 805 ; of the brain, case of, 424 ; of the pericardium, 560 : of the chest, 579, 587 ; of the abdomen, 510, 514 Dropsy, ovarian, cases of, 763; pathology of, 775 ; diagnosis of, 779; treatment of, 780; pro- ducts found in fluid of, 103 Duodenum, perforating ulcer of, 789 Dyspepsia, cases of, 472; pathology, treatment and causes of, 475 Dysentery, cases of acute, 526; case of chronic, 527 ; pathology of, 530 ; treatment of, 533 Eclampsia, definition of, 449 Ecthyma, diagnosis of, 832 ; treatment of, 833 Eczema, diagnosis of, 832 ; treatment of, 837 Electricity, therapeutic uses of, 329 Embolismus, 399 Emboli, in the brain, pathology of, 397 ; in the lung, 721 Emphysema, pathology of, 655; cases of, 654, 657 ; treatment of, 658 Emprosthotonos, definition of, 448 Empyema, cases of, 667 ; paracentesis for, 675 1016 Encephaloma, 230 Enchondroma, 220; structure of, 221; diagnosis of, 222 Endocarditis, 575 Engorgement, bleeding useful in, 317, 711 Entozoon folliculorum, description of the, 845 Ephelis, diagnosis of, 833; treatment of, 840 Epilepsy, definition of, 353, 449 ; case of relieved by galvanism, 452; case of, from chronic cere- britis, 376 Epithelial growths, 210. See Epithelioma Epithelial, scales in saliva, 88; ulcer, 109; growths, 210 Epithelioma, 210; principal forms of, 210; struc- ture of, 213 ; of the lip and tongue, 213 ; of the lymphatic glands, 214; of the urinary bladder, 215 ; pathology of, 236 Epithelium, fringe-like, 89 Epulis, 226 Eremacausis, 171 Ergot of rye in paraplegia, 434 Eruptions, cutaneous, microscopic examination of, 107 Erysipelas, cases, diagnosis, and treatment of, 961 Erythema, diagnosis of, 832; treatment of, 837 Ethics of medicine, 999 Examination of patient, 24; by interrogation, 24 ; by inspection, 36; by palpation, 43 ; by mensuration, 45; by succussion, 44; by per- cussion, 48 ; by auscultation, 63 Examination, post-mortem, 30; method and order of, 30 ; object of, 30; of external appear- ances, 31; of head, 81; of spinal column, 31; of neck, 31; of chest, 31; of abdomen, 32 ; of blood, 32 ; by microscopic examination, 32; hints for carrying out post-mortem examina- tion, 32 ; knowledge required for correct ex- amination, 33; necessary to determine the value of remedies, 627 ; Dr. Sibson's " Medi- cal Anatomy," 34 Exanthemata, definition of, 828; diagnosis of, 832 ; treatment of, 837 Excrescence, cauliflower, 213 Excretion of matters from the body, 133; amount of, 134 Exercise, therapeutic uses of, 323 Exophthalmia, case of, 384 Exostosis, 225; from poisoning with mercury, 978 Expectoration and cough in phthisis, treatment of, 749 Experience, past and present, in the treatment of inflammation, 304 Exudation, definition of the term, 162, note; production of, 158; theory of, 159; cancerous, 235 ; tubercular, 181 ; death of the, 169 ; gen- eral treatment of, 176, 184; fatty degenera- tion of the, 260; mineral degeneration of the, 271; essential to inflammation, 303, 304; transformation of, in pneumonia, 689; in cerebritis, 387 ; in pericarditis, 174; in pleuri- tis, 665; seat of in dysentery, 532 Face, remarkable case of atrophy of, 155 Patty concretions, 273 Fatty degeneration, 252; of cells, 253; of muscle, 254; of blood-vessels, 256; of the placenta, 258 ; of cartilage, 259; of bone, 259; of the exudations, 260; of morbid growths, 261; of the brain, 354; of the liver, 512; of the cardiac valves, 597 ; of the heart, 598; of the kidney, S21 Fatty growths, 193 ; steatomatous and lipoma- tous, 197 ; fibro-lipomatous, 197 Favus crust, composition of, 108 Favus of the scalp, diagnosis of, 834 ; cases of, 847 ; history of favus as a vegetable parasite, 850; mode of development and symptoms of, 850 ; causes of, 853 ; pathology of, 855 ; treat- ment of, 862; on the face of a mouse, 853, note Febricula, characters of, 920 ; cases of, 921 Febrile symptoms in phthisis, treatment of, 732 Fern, male shield, as a vermifuge, 542 Fever, continued, changes of type in, 305, symptoms of, 918; forms and characters ofj 920; diagnosis of, 931; morbid anatomy of the Edinburgh epidemic of, during 1846-7, 934; causes of, 942; treatment of, 945 Fever, intermittent, case of, 951; nature of, 952; treatment of, 952 Fever, relapsing, character of, 920; case of, 923 ; identical with the synocha of Cullen, 924 Fever, remittent, case of, 949 ; nature and treat- ment of, 950 Fever, therapeutic action of quinine in, 948 Fever, typhoid, character of, 920; cases of treated by quinine, 924; diagnosis of, 931 nature of, 937 ; morbid anatomy of, 934 etiology of, 937 Fever, typhus, character of, 920 ; case of, treated by quinine, 927; cases of, treated without quinine, 930; diagnosis of, 931; treatment of, 945 Fevers, eruptive, 953 Fibres, molecular, 189 ; nuclear, 189 ; cell, 189 Fibrin, in the blood, 92; not altered by vene- section, 133 Fibroma, 188 Fibrous growths, 188; molecular, nuclear, and cell, 189; fibro-nucleated and fibro-cellular, 190; sarcomatous or soft, 191; dermoid or hard, 193 ; neuromatous, 195 Fistula, recto-vesical, 795 Fluctuation, examination of patient by, 44 Faeces, microscopic examination of, 99; in diar- rhcea, 525 ; in constipation, 526; characters of in disease, 530 Food, various kinds of, 125 ; circumstances regu- lating, 125 ; assimilation of the, 128 ; effects of bad assimilation, 136; effects of improper quantity or quality of, 154; therapeutic uses of, 320; in scorbutus, 993 Foramen ovale, enlarged, case of, 592 Force, attractive and selective, 131 Freckle, diagnosis of, 833; treatment of, 840 Functions, influence of derangement of one over another order of, 154 Functions of the body, influence of predominant ideas on the, 285 Fungus haematodes, 230 Fungus from a favus crust, 108; in the ear, 108 Gangrene, moist, 169 ; dry, 171; of the intes- tine, 535 ; of the lungs, 716; from obstruction of pulmonary artery, 721; of the kidney, 795 Gall-bladder, with gall-stones in, 504, 509 ; en- largement of, 506 Gall-stone, 273; case of impaction of, in com- mon bile-duct, 504; passage of into the gall- bladder, 506 Gastric glands, organic changes in, 493 Genito-urinary system, examination of, 27; action of medicines on the, 342 ; diseases of the, 762 Gland, thyroid, liability of to new formation of tissue, 208; enlargement of, in bronchocele, 251 Glands, mesenteric, liability of, to increased growth, 208 Gland, prostate, calculi found in the, 278 Glands, structure of blood-forming, 886 Glandular growths, 206 ; forms of, 207 ; structure of, 207 ; of the thyroid gland, 208; of the lymphatic glands, 208; causes of, 209 Glottis, cases of acute oedema of the, 642 Glycohaemia, cases of, 907; theories regarding the nature and treatment of, 909 ; treatment of by sugar, 912; tabulated cases of, with analysis, etc., 914 Gout, general pathology and treatment of, 982 ; case of chronic, 991 Granulations, formation and structure of, 168 INI INDEX. 1017 Granule cells, 167, 253 Granules and molecules, deposition of fatty, 253 Growths, morbid, 185; classification of, 187; ultimate elements of, 186; general pathology of, 233 ; origin of, 233 ; development of, 234; propagation of, 237 ; malignancy and non- malignancy of, 238; curability of, 239; Van der Kolk's views of causes of propagation of, 241; decline or degeneration of, 242 ; general treatment of, 242 ; means of retardation and resolution of, 243; means of extirpation of, 243 ; necessity for microscopic examination of, 243; constitutional treatment of, 244; M. Velpeau on the permanent removal of, 245; fatty degeneration of, 261; mineral degenera- tion of, 271 Growths, morbid, of texture, 185 ; fibrous, 188 ; fatty, 196 ; cystic, 199; melicerous, 199; cho- lesteatomatous, 202 ; atheromatous, 203; glan- dular, 206 ; cartilaginous, 220; erectile, 218 ; steatomatous encysted, 202 ; epithelial, 210; vascular, 216; osseous, 225; myeloid, 226; cancerous, 229; distinction of cancerous from other, 229 Gruby's pocket microscope, 79 Haematocele, appearance of altered blood cor- puscles in the fluid of an, 92 Haemoptysis in phthisis, treatment of, 751 Hairy, formations, 215 ; concretions, 279 Hammer, Dr. "Winterich's, 49 Head, post-mortem examination of, 31 Headache, definition of, 447 ; treatment of, 453 Headland, on the actions of medicines, reviewed, 333 Healing process, results of the, 185 Health and disease, general laws of nutrition in, 124; general laws of innervation in, 137 Heart, functional disorders of the, 600; treat- ment of, 601 Heart, rules for the diagnosis of diseases of the, 557 Heart, sounds of the, 71; percussion of the, 56; mechanical injuries of the valves of, 594; exu- dation into or on the surface of the valves of, 595; deposition of fibrin on the valves of, 597 ; degeneration of the valves of the, 597 ; fatty degeneration of the, 598; hypertrophy ot the, 598 ; inflammation of the substance of the, 599 Heart, valvular diseases of the, 575; cases of, 576; causes of, 594; pathology of, 594; treat- ment of, 599 ; dislocation of the, 677 Heat, source of animal, 35; therapeutic uses of, 326 Hemiplegia, definition of, 448; cases of, 392; pathology of, 418; treatment of, 420 Hemlock, case of poisoning by, 459; symptoms of, 462 ; physiological action of, 463 ; death of Socrates by, 464; identity of ancient with modern, 464 Hemorrhage, cerebral, cases of, 400; predispos- ing cause of, 417 ; microscopic appearances of, 417 ; diagnosis of, 418 ; treatment of, 420 Hepatitis, case of, 497 Herpes, diagnosis of, 832 ; treatment of, 838 Hooping cough, 649 Homy productions, 216 Husband, Dr., his mode of preserving vaccine lymph, 966 Hutchinson's spirometer, 48 Hydatid cyst of the liver cured, 522 Hydrocele, 200 non *. „ „* Hydrocephalus, acute, cases of, 360 ; nature of, 364 ; treatment of, 365 llvdrocephalus, chronic, case of, 424 Hydro-pericardium, 560; pathology of, 570, treatment of, 573 Hydrophobia, definition of, 448 Hydrophone, 65 Hydro-thorax, 579, 587 Hygienica, 323 Hypertrophy, 186 ; of the liver, 510; of tho heart, 598 Hypnotism, 290 Hysteria, definition of, 448; treatment of, 454 Ichorhaemia, case of, 902 ; theories regarding the Ichthyosis, diagnosis of, 833; treatment of, 840 Ideas, predominant, influence of, on the func- tions of the body, 284 Ileus, case of, 535; following ovariotomy, case of, 763; pathology of, 537 ; treatment of, 538 Illusions, spectral, cases of, 445, 455 ; theory of, 290 Impetigo, diagnosis of, 832; treatment of, 838 Incompetency of aortic valves, cases of, 577 ; of mitral valve, cases of, 579; of tricuspid valve, cases of, 587 Induration, 186 Infection, definition of, 953; purulent, 886 Inflammation, Andral's opinion of the expres- sion, 160 Inflammation, 155 ; phenomena of, 155 ; theory of, 158; definitions of, 160 ; terminations of, 164; general treatment of, 176; fallacious character of past experience in the nature and diagnosis of, 303; unchangeable nature of, 305; natural progress of, 313; diminished employment of blood-letting in acute, 302 ; former reasons for bleeding erroneous, 306; cannot be cut short, 313; value of bleeding in, 315; effects of general and local blood-letting in, 309 ; character of the pulse as an indica- tion for blood-letting in, 312 ; real use of blood-letting in, 317; effects of mercurials in, 318; antiphlogistic practice injurious in, 318 ; blood-letting controversy in, 319. See also Exudation Influenza, nature and treatment of, 652 Innervation, general laws of, in health and dis- ease, 137 Innervation, function of, 137 ; influence of dis- ordered nutrition on, 154 Inoma, 187, 188 Insalivation, 126 Insanity, definition of, 447 Inspection, examination of patient by, 36; of the general posture, 36; of the countenance, 36 ; of the chest, 36 ; of the abdomen, 37; of the pharynx, 38 ; of the larynx, 39; of the posterior nares, 42 Integumentary system, action of medicines on the, 343 ; diseases of the, 872 Integumentary system, examination of, 27 Intestinal concretions, 280 Intestine, case of obstruction of the large, 534 Intestines, percussion of, 60; diseases of the, 524 ; condition of, in typhoid, fever, 935 Intestine, small, case of strangulation and per- foration of, from inguinal hernia, 535 Iritis, case of rheumatic, 990 Irritation, spinal, definition of, 448 Itch, insect, description and treatment of the, 842 Jaundice, cases of, 498, 504, 506, 509 Kamala, as a vermifuge, 545 Keloid growths, case cf, 973 Kidney, percussion of the, 61; waxy degenera- tion of the, 249 ; calculi in the, 275 ; inflam- mation of the, 782 ; abscess in the, 791; scrof- ulous abscesses in, 793; calculous inflamma- tion and gangrene of, 795 ; chronic inflamma- tion of, and cystic, 797; origins of cystic dis- ease of the, 799 ; Bright's disease of the, 801; remarkable case of Bright's disease of the, recovering under the influence of super-tart- rate of potash, 805; atrophied, 817. See Bright's disease, also Nephritis Laryngismus stridulus, 651 1018 Laryngitis, cases of, 638; method of applying topical remedies in, 640; symptoms of, 642; diagnosis of, 647 ; treatment of, 648 Laryngitis, syphilitic, case of, 972 Laryngoscope, 39 Larynx, inspection of the, 39; appearance of in health, 40; in disease, 41 Lead, case of poisoning with, 464 ; treatment of, 465 Lenses, objective, of microscopic, 81 Lentigo, diagnosis of, 833; treatment of, 840 Lepra tuberculosa, diagnosis of, 833 ; vulgaris, diagnosis of, 833; treatment of, 839 Leucocythemia, 867 ; definition of, 868; cases of, 868 ; pathology and treatment of, 880; dis- covery of, 892 ; appearance of blood in, 93 Lichen, diagnosis of, 833 ; treatment of, 839 Life, Beclard's definition of, 114 Light, therapeutic uses of, 329 Lime, oxalate of, microscopic appearance of, 104 Lipoma, 197 Lithic acid calculi, 276 Liver, percussion of, 57; waxy degeneration of the, 240, 514; diseases of the, 497; case of acute congestion of the, 497 ; abscess of the, 501, 618 ; cases of enlargement of the, 510; fatty enlargement of the, 511; cirrhosis of the, 514 ; cancer of the, 518 ; nutmeg, 517 ; hyda- tid cyst of the, cured, 522 ; syphilitic deposits in, 503 Lungs, percussion of, 53 ; abscess of the, 713, 718 ; case of gangrene of the, 716 ; condition of, in typhus fever, 934; fistulous openings in, 667 ; partial atrophy of the, 791; compression of the, in empyema, 674; collapse of the, 653 ; cedema of the, 785 ; haemorrhage into the, 579, 583 ; inflammation of the. See Pneumonia, and names of special diseases of the Lungs, cancer of the, case of, 754; forms, diag- nosis, and treatment of, 755 Lungs, carbonaceous, cases of, 756 ; nature and causes of, 758 ; treatment of, 702 Lupus, diagnosis of, 833 ; treatment of, 840 Lymph, plastic formation and structure of, 165 Lymphatics, inflammation of, 635 Macula, definition of, 829; diagnosis of, 833; treatment of, 840 Magnesia, triple phosphate or ammonio-phos- phate of, microscopic appearance of, 104 Magnetism, animal, 287 Malignancy, in morbid growths, discussed, 237 Mamma, compound cystic sarcoma of, 200; cause of increased growth in, 209 Mastication, 126 Materia medica, 331 Medical bill which passed the legislature in 1858, 14 Medicine, relation of the science to the art of, 2 ; present state of practical, 20; principles of, 114; ethics of, 999 Medicines, curative actions of, 335; action of on the ultimate elements of the tissues, 336; action of, on the nervous system, 337 ; action of, on the respiratory system, 339; action of, on the circulatory system, 339; action of, on the digestive system, 341; action of, on the genito-nrinary system, 342 ; action of, on the integumentary system, 343 ; general theory of the action of, 344 Melanin, 267 Melanoma, 265 Meningitis, cerebral, cases of, 367 ; seat of, 370 ; microscopic examination of, 371; diagnosis of, 371; treatment of, 371; pathology of, 372 Meningitis, spinal, case of, 427 Menstrual discharge,microscopic appearance of, 100 Mensuration, examination of patient by, 45 Mentagvu, diagnosis, of, 834 ; treatment of, 838 Mercurial poisoning, 971; of neuro-spinal func- tions, 453 ; in a dog, 978 Mercury, inutility of, in inflammations, 177, 318; in acute hydrocephalus, 366; in jaundice, 505 ; in pericarditis, 574 ; Graves' extravagant praises of, opposed by facts, 575 ; injurious in syphilis, cases of^971, 973; treatment of syphi- lis by, 980; not necessary in iritis, 991 Mesenteric artery, aneurism of, 620 Mesenteric glands, in typhoid fever, 936, 209; hypertrophy of, in leucocythemia, 868 Mesmeric mania of 1851, 294> Mesmerism, 285 Metallic tinkling, 69; in pneumo-thorax, 669, 671; cause of, 675 Micrometer, 84 Microscope, use of the, in examination of pati- ent, 75; Oberhaeuser's, 77; Gruby's compound pocket, 79; Beale's clinical, 80; objective lenses of, 81; eye-piece, 82 ; methods of illu- mination, 82 ; test objects for the, 83 ; methods of mensuration and demonstration, 83 ; how to observe with a, 85 ; principal applications of, to diagnosis, 87; necessity of employing, to determine the nature of cerebral and spinal softenings, 352 ; examination of the saliva, 88; milk, 89 ; blood, 91; pus, 93 ; sputum, 94: vomited matters, 97 ; faeces, 99; uterine ana vaginal discharges, 100 ; mucus, 102 ; dropsical fluids, 103 ; urine, 103; cutaneous eruptions and ulcers, 107 Microscopic objects, physical characters which distinguish, 85 Milk, microscopic examination of, 89 Mind, evolution of the power of, dependent on the hemispherical ganglion, facts in proof of, 139 Mineral substances essential to nutrition, 125 Mineral degeneration, 269; of blood-vessels, 269 of nervous texture, 270; of the exudations, 271; of morbid growths, 272 Mineral concretions, 275 Mitral valve, cases of disease of, 579 Molecules and granules, deposition of fatty, 253 ; basis of the tissues, 119 ; agency of, in genera- tion, 120; in nutrition, 121 Molecular theory, of organisation, 115; of the author, 118 ; opposed to that of the cell patho- logists, 121; the basis of the arts of horticul- ture, agriculture, and medicine, 123 ; well il- lustrated, 135 ; importance in therapeutics, 351 Moles, diagnosis of, 833 Molluscum contagiosum, 201; diagnosis of, 833 Mono-ideism, note, 292 Moore's test for sugar in urine, 111 Morbid growths, 185. See Growths Mortification, or moist gangrene, 169 Motion, contractile, diastaltic, and voluntary, 147 Motions, irregular, definition of, 448 Mouth, diseases of the, 466 Movements, contractile, diastaltic or reflex, and voluntary, 147 Mucus, gelatinous, structure of, from os uteri, 100; microscopic examination of, 101 Muscle, fatty degeneration of, 254 Muguet, minute structure of exudation in, 89 Murmurs, laryngeal and tracheal, 67; bronchial, 67 ; vesicular respiratory, 67 ; cavernous, 68 ; amphoric, 68 ; sonorous, 69 ; dry vibrating, 69 ; sibilous, 69; bellows, 73 ; exocardial and endo- cardial, 73; pericardial or friction, 73; val- vular or vibrating, 73 ; musical, in heart, 73, 583 Muscular sense, 143 Myelitis, acute case of, 428 ; chronic cases of, 432 Myocarditis, 599 Nam, diagnosis of, 833 ; treatment of, 840 Nares, posterior, inspection of, 42 Nausea and vomiting, treatment of in phthisis, 750 Neck, post-mortem examination of, 31 Nephritis, acute, cases of, 782 ; desquamative, INDEX. 1019 785 ; hsemorrhagic, 787 ; scrofulous, 793 ; cal- culous, 795; chronic, 797 Nerves of special sense, definitions of irritation of, 449 Nerves, structure and functions of, 145; gan- glionic system of, 146 Nervous system, examination of, 26; general anatomy and physiology of the, 138 ; structure and arrangement of the, 138; reflex and dias- taltic actions of, 139 ; functions of the brain, 139; functions of spinal cord, 144; general pathology of, 148 ; effects of stimuli or disease on the functions of the, 152 ; influence of rapid and slow lesions of, on symptoms, 153; in- fluence of seat of disease on nature of pheno- mena, 152 ; production of similar phenomena in various lesions and injuries of the, 153; in- fluence of, on nutrition, 154 Nervous system, diseases of the, 352 Nervous system, functions of the, 139; action of medicines on the, 337 ; functional disorders of the, 445 ; classification of, 447 ; pathology of, 449; causes of, 450 ; treatment of, 453; case of, 445 ; congestive disorders of the, 450 ; dia- staltic or reflex disorders of the, 451; toxic dis- orders of the, 452 Nervous texture, mineral degeneration of, 370 Nervous trunks, effects of direct mechanical in- jury on, 154 Neuralgia, definition of, 449; from cancer of cranial bones, 441; treatment of, 445 Neural disorders, classification of, 449 Neuroma, 191, 195 Neuro-spinal disorders, classification of, 449 Nihilismus, 23 Noli me tangere, 213 Noma, 171 Nutrition, complemental, 307 Nutrition, general laws of, in health and disease, 124 Nutrition, function of, 124 ; division of process into five stages, 125 ; introduction of appro- priate alimentary matters, 125; formation from these of a nutritive fluid, the blood, and the changes it undergoes in the lungs, 128 ; pas- sage of fluid from the blood to be transformed into tissues, 130 ; disappearance of transformed tissues, and their re-absorption into the blood, 131; excretion of these effete matters from the body, 133 Nutrition, importance of albumen, oil, and mineral substances in the process of, 125 Nutrition, diseases of, 136 ; causes of, 137 ; prin- ciple of treatment of, 137 Nutrition, disordered, influence of, on innerva- tion, 154 Oberhaeuser's microscope for medical men, 77 Obesity, 196 ; case of, 907 ffidema, of the brain, 356 ; of subarachnoid cel- lular tissue, case of, 380 ; of the legs, from cirrhosis, 527 ; from cardiac disease, 587 ; of the glottis, 642 ; of the lungs, 785 ; from albu- minuria, 802 Gigophony, 69 lEsophagus, case of stricture of from epithelioma, 467 ; cancer of, 384, 470, 518 Oil and albumen, importance of in the process of nutrition, 125 Oligocythemia, 902 Opisthotonos, definition of, 448 Opium, case of poisoning by, 458 Organs, circulatory, auscultation of, 70; sounds elicited by, in health and disease, 71 ; modifi- cations of healthy, sounds, 72 ; new or abnor- mal sounds, 73 Organs, natural position of, 33; displacement of, remarkable cases of, 35, 674 Organs, pulmonary, auscultation, 66; sounds produced by, 66 ; circulatory, auscultation of, 70 ; sounds produced by, 71 ; abdominal, aus- cultation of, 73 Osseous growths, 225 ; seats of, 225 ; myeloid. 226 ; new, 227 ; in the eye and other textures, 227 Osteochondrophytes of Cruveilhier, 221 Osteoma, 225 Osteoma, cystic, of femur and tibia, 201 Osteo-sarcoma, 191, 222 ; observations of Goodsir and Bedfern on, 223 Otorrhcea, 427 Ovarian dropsy, cases of, 763 ; pathology of, 775; diagnosis of, 779 ; treatment of, 780 Ovariotomy, case, 763" Oxalic acid, poisoning by, 495 Oxaluria, cases of, 473 Painters' colic, case of, 464 Palpation, examination of patient by, 43; of aneurisms, 630 Palpitations of the heart, causes and treatment of, 600 Pancreas, cases of cancer of, 489, 509; Bernard's views of the functions of, 510 Papilloma, 211 Papulae, definition of, 829; diagnosis of, 833 ; treatment of, 839 Paracentesis capitis, 425; thoracis, 671; abdo- minis, 764 Paralysis, definition of, 353 ; cases of, 386, 428 ; definition of local, 449 ; of abducens oculi and auditory nerves, 386 Paraplegia, definition of, 448; cases of, 430 ; cause and treatment of, 436 Parasites, animal, 842 ; vegetable, 847 Pathology, effects of advanced knowledge of, 297 Patient, method of examination of, 25 ; circula- tory system, 26 ; respiratory system, 26 ; ner- vous system, 26 ; digestive system, 26 ; genito- urinary system, 27 ; integumentary system, 27 ; antecedent history, 27; hints for carrying out examination, 28 Patient, examination of by inspection, 36; by mensuration, 45 ; by fluctuation, 44 ; by pal- pation, 43 ; by percussion, 48 ; by auscultation, 63 ; use of microscope in examination of, 75 ; use of chemical tests in examination of, 111 Pectoriloquy, 67 Pemphigus, diagnosis of, 832 ; treatment of, 838 Percussion, examination of patient by, 48 ; dif- ferent sounds produced by, 50 ; sense of resist- ance produced by, 51; general rules for prac- tice of mediate, 51 Percussion of particular organs, special rules for, 53 ; of lungs, 53 ; of heart, 56 ; of liver, 57 ; of spleen, 59 ; of stomach and intestines, 60 ; of kidneys, 61; of bladder, 62 ; of aneur- isms, 630 Percussion hammer, utility of, 49 Perforation of the stomach, cases of, 483 ; of the duodenum, 789 ; of the intestine, from hernia, 535 Pericarditis, changes which take place in the exudation of, 174 ; cases of, 559 ; pathology of, 570; diagnosis of, 571; complication of, 573 ; treatment of, 573 Peritonitis, cases of, 545 ; acute, 545 ; tubercular, 549; cancer of abdominal organs, resembling, 551; cancerous, 554 Pertussis, 649 Pharyngitis, case of follicular, 467 Pharynx, diseases of the, 466; inspection of the, 38 Phlebitis of left iliac vein, 634 Phlcholites, 194 Phosphorus, in spinal diseases, 433 Phthisis of colliers, appearance of sputum in, 97, 266 ; cases of, 756 ; nature and causes of, 758 ; treatment of, 762 Phthisis pulmonalis, cases of, 722 ; natural pro- gress of, tendency to ulceration, and modes ol arrestment of, 733; pathology and general treatment of, 741; indications for the treat- ment of, 742 ; cod-liver oil as a remedy for, 744; value of microscopic examination oi 1020 sputum in, 95 ; special treatment of, 749; cough and expectoration, 749 ; loss of appetite, 750; nausea and vomiting, 750; diarrhoea, 751; haemoptysis, 751 ; sweating, 751; febrile symp- toms, 752; debility, 753; despondency and anxiety, 753 Picrotoxine, effects of, 453 Pigmentary degeneration, 262 ; general patho- logy and treatment of 267 ; concretions, 274 Pigment, formation and varieties of, 262 ; causes of, 267 Pityriasis, diagnosis of, 833 ; treatment of, 840; parasitic, cases of, 864 Piorry's pleximeter, 49 Placenta, fatty degeneration of the, 258 Pleuritis, cases of, 660; pathology, diagnosis, and treatment of, 664; chronic cases of, 663 Pleurosthotonos, definition of, 448 Pleximeter of M. Piorry, 49 Pneumonia, acute, microscopic appearance of sputum in, 96, changes which take place in, 173 ; natural progress of a, 316; treatment by bleeding, 692; results of antiphlogistic treat- ment of, 693 ; results of dietetic treatment of, 694; results of treatment by large doses of tartar emetic, 694; results of mixed treatment, 695; results of restorative treatment directed to further the natural progress of the disease, 696; bleeding, a palliative in, 711; cases of, 678 ; a table of 129 cases of, 698; diagnostic value of the absence of chlorides from the urine in, 686; general pathology and treat- ment of acute, 692 ; chronic cases of, 713 Pneumo-thorax, cases of, 669; remarkable death in a case of, 671 ; metallic tinkling in, 675 Poisoning by alcohol, 455; by opium, 458 ; by hemlock, 459; by lead, 464 ; by oxalic acid, 495 ; by sulphuric acid, 496 ; by corrosive sub- limate, 496 ; by aconite, 628; by mercury, 971. Polycythtemia, 902 Polydipsia, cases of, 995 Polypus, soft, 193; hard, 194 ; in the heart, 590 Polysareia, 997 Porrigo, definition and varieties of, 835 Post-mortem examination, 30; method and order of, 30 ; hints for carrying out, 32 ; knowledge required for, 33 Posture of patient, inspection of, 36 Praesystolic murmur, 585, 586 Pressure and compression, distinction between, 149 Probang, method of using, in laryngitis, 640 Prostatic concretions, 278 Prurigo, diagnosis of, 833 ; treatment of, 839 Psoriasis, diagnosis of, 833 ; treatment of, 839 Psychologists, their mode of studying insanity, 142 Pulmonary organs, special rules for auscultation of, 66; sounds produced by, 66 Pulmonary diseases, injections of the bronchi in, 658; case of, 657 Pulmonary artery, varicose aneurism of, 608 Pulse, characters of, 26; as an indication for bleeding, 312 Purgatives, use of, in intestinal disease, 526 Purpura, diagnosis of, 833; treatment of, 840 Pus, microscopic examination of, 93, 166 ; forma- tion of, in pneumonia, 173 ; scrofulous, micro- scopic appearance of, 94, 166; effects of mix- ture, with the blood, 904; injection of, into the blood, 906 Pustulae, definition of, 828; diagnosis of, 832; treatment of, 838 Pyaemia, case of, 902; theories regarding the nature of, 904 Pyelitis, cases of, 782 Pyrosis, 479 Quain's stethometer, 45 Quinine in continued fever, therapeutic action of, 948; in intermittent fever, 952 ; in hectic fever, 753 Rammollissement. See Softening Rattles, moist, b8 Recto-vesical fistula, case of, 79 Remedies, indications for the use of, 297. Sea Medicines Renal calculi, 257 Resolution, 173 Resonance, vocal, 66 Respiration, motions of chest during, 36 Respiration natural and exaggerated, 66; puerile, 67 ; alterations of, 67; function of, 129 ; Dr. E. Smith's experiments in, 129; effects of, on the blood, 129 Respiratory sounds, 66 ; alterations in natural, 67 ; new or abnormal sounds of, 68 Respiratory system, examination of, 26; action of medicines on the, 339 ; diseases of the, 637 ; rules for the diagnosis of, 637 Rest, therapeutic uses of, 324 Reticulum of cancer, 260 Rheumatism, general pathology and treatment of, 982; treatment of, by nitrate of potash, 984; treatment of, by lemon-juice, 988; dia- phragmatic case of, 989 ^ Rhinoscope, 42 Ringworm, 841 Roseola, diagnosis of, 832 ; treatment of, 837 Rupia, diagnosis of, 832 ; treatment of, 839 Saliva, microscopic examination of, 88; function of, 126 Sanguification, 128 Sarcina ventriculi, 98 Sarcoma, 191; cystic, 205 : compound cystic, of the mamma, 200; osteo, 191, 222 Scabies, diagnosis of, 832; treatment of, 838 Scalp diseases, treatment of, 840 Scarlatina, cases of, 954 ; diagnosis and treat- ment of, 955 ; colchicum in, 959; bodies found in urine in a case of, 108 Scirrhus, 229 Scorbutus, cases of, 993 ; epidemic of, in Edin- burgh, 993 ; observations of Dr. Christison and Dr. Lonsdale on, 994; Dr. Garrod on, 995 Scrofula. See Tuberculosis Scrofulous pus-cells, 94, 166 Sectio cadaveris, method and order of, 30; object of, 31; external appearances, 31; head, 31; spinal column, 31; neck, 31; chest, 31; abdo- men, 32 ; blood, 32 ; hints for carrying out post-mortem examination, 32 ; knowledge re- quired for correct examination, 33 Sensation, definition of, 147 Sensibility, definition of, 148 Sibson, Dr., his " Medical Anatomy," 34; his chest-measurer, 46 Silver, nitrate of, action and use of, in laryngitis, 639 Skin diseases, classification of, 828 ; definitions of, 828 ; diagnosis, 831; varieties of, 834; treatment of, 836; scaly diseases of, 211; treat- ment of, 839 ; treatment of syphilitic diseases of the, 841 Small-pox, cases of, 962 ; general treatment of, 963; ectrotic treatment of, 963; greater fre- quency of, 965 ; relation of, to varicella, 968 ; identical with cow-pox, 968 Socrates, his death by taking hemlock, 463 Softening, cerebral and spinal, pathology of, 353; exudative or inflammatory, 354; hemorrhagic, 355 ; fatty, 355; serous or dropsical, 356 ; mechanical, 356 ; putrefactive, 357 ; necessity for microscopic examination of, 359 ; cases of, 359 ; cerebral cases of, 380; spinal cases of, 434 Solanoma, 222 Sounds produced by percussion, 50 ; elicited over lungs, 53 ; produced by pulmonary organs, 66 ; cracked-pot, 58 ; alterations of natural, 67 ; abnormal, 68 ; rubbing or friction, 68 ; relative value of in auscultation, 70 ; of the circulatory organs, 71; diagnostic of diseases of the cir- culatory system, 557 ; of aneurisms, 631; diag- INDEX. 1021 nostic of diseases of the respiratory system, 637 Spasm, definition of, 353, 448 ; of the jaw, case of, 408 Spermatocele, appearance of spermatozoids in fluid of, 103 Spinal column, post-mortem examination of, 31 Spinal cord, structure and. functions of, 144 Spinal softening, pathology of, 353 ; origins and varieties of, 354; necessity for microscopic examination of, 359 ; cases of, 434 Spinal irritation, definition of, 448 Spinal disorders, classification of functional, 448 Spirometer of Mr. Hutchinson, 48 Spleen, percussion of, 59 ; waxy degeneration of the, 249; hypertrophy of, in leucocythemia, 868, 881; morbid anatomy of, in fever, 934 Sputum, microscopic examination of, 94; value of microscopic examination of, 95; microscopic appearance of in acute pneumonia, 102; ap- pearance of in black phthisis of colliers, 97, 267 ; elastic tissue in, 96 Squamae, definition of, 829; diagnosis of, 823; treatment of, 839 Starvation, symptoms of, 154 Steatoma, 197, 203 Stetho-goniometer, of Dr. Scott Alison, 48 Stethometer of Dr. Quain, 45 Stethoscope, 63 ; hints for choice of, 64 ; Can- man's, 64; differential, of Dr. Scott Alison, 64; flexible, 64 Stomach, percussion of, 60 ; hairy concretions in the, 279 ; functional disorders of the, 472 ; or- ganic diseases of the, 481; ulceration of the, cases of, 481 ; perforation, cases of, 483 ; fre- quency of ulceration in, 488 ; symptoms and treatment of ulcers in, 489; cases of cancer of the, 489 ; structural changes in glands of, 493 ; remarkable cases of emphysema of the coats of, 671 Stramonium, action of, 453 Stricture, 186; of intestine, 534, 535, 763 Strychnine, action of, 453 Succussion, examination of patient by, 44 Sugar in urine, detection of, 111; trial of in the treatment of diabetes, 9l3 Sulphuric acid, poisoning by, 496 Supra-renal capsules, Dr. Addison's views of, 264; case of disease of, without bronzing of skin, 714 Sweating in phthisis, treatment of, 751 Syphilis, cases of, 971; observations on, 974; symptoms of, 974; diagnosis of, 975 ; propaga- tion of, 976 ; pathology of, 977 ; treatment of, Syphilitic diseases of the skin, treatment of, 841; deposits in the liver, 503 . System, nervous, general anatomy and physio- logy of, 138 ; general pathology of, 148 Taenia solium, origin and development of the, 539 ; cases of, 542; treatment of, 544 Tape-worm. See Taenia solium Temperature of fevers, 933 Tests, chemical, use of in examination ol pa- tient, 110 Tetanus, definition of, 448 Therapeutics, general, 284; recent changes in, 12 ; as affected by the influence of the mind, 284; by the natural progress of disease, 295 ; bv an improved diagnosis and pathology, 297 ; bvthe diminished employment of bloodletting and antiphlogistics, 302; of the dietetica, 320; of the hygienica, 323 ; of the materia medica, 331 Thermometric observations in fevers, 933 Thoracentesis, 675 ., Thorax, inspection of, 36 ; mensuration of, 45 , motions of during respiration, 36 ; postmor- tem examination of, 31; view of viscera in, 34 Thrombosis, 399 .,,„.» a.- Tissues, structural relations of, 119 5 formation and sustentation of, by the blood, 130; attrac- tive and selective property of the, 131; re- absorption of transformed tissues into the blood, 131; action of remedies on the ultimate, 336 - * „.= ^-a Texture, morbid degenerations of, 245; morbici growths of, 185 Tonsillitis, 466 Toxic disorders of the nervous system, 4SJ; treatment of, 455 Trance, definition of, 448 Tracheotomy, in laryngitis, 643 Treatment, an inquiry into our present means of, 320. See Therapeutics Tricuspid valve, cases of disease of, 587 Trismus, definition of, 448 Trommer's test for sugar in urine, 111 Tubercle, definition of, 179; forms of, 179 ; mi- nute structure of, 179 ; corpuscles, 95, 179; chemical composition of, 181; pathology of, 181 Tubercula, definition of, 829 ; diagnosis of, 833; treatment of, 840 Tuberculosis, 179; general pathology of, 181, 741; natural progress of, 182 ; general treat- ment of, 183, 741. See Phthisis Tumeur h6teradenique of M. Robin, 208 Tumors, classification of, 187 ; fibrous, 188; sar- comatous or soft fibrous, 191; dermoid or hard . fibrous, 193 ; neuromatous fibrous, 195 ; fatty, 196; fibro-lipomatous, 197 ; cystic, 199 ; simple cystic, 199; compound cystic, 200; osseo-cystic, 204; glandular, 206; epithelial, 210 ; horny, 216 ; aneurismal, 217 ; cases of, 601; erectile, 218; varicose, 218; enchondromatous, 220; osseous, 225 ; myeloid, 226; cancerous, 229 Typhus and typhoid fevers. See Fever. Ulcer, cancerous, of skin, microscopic appear- ance of, 109 ; cutaneous, microscopic examina- tion of, 108; of tonsil, case of, 466; of oesopha- gus, 468 ; of stomach, 481; of duodenum, 789; of intestine, 535; typhoid, 935 Ulceration, 172 University (Scotland) Bill, 15 Uric acid, microscopic appearance of, 105 Urinary concretions, 275 Urine, microscopic examination of, 103 ; specific gravity of, 110; detection of albumen in, 110; detection of bile in, 110; detection of bile acids in, 111; of leucin and tyrozin in, 111; detection of sugar in, 111; detection of chlo- rides in, 112 ; diagnostic value of the absence of chlorides from the, in pneumonia, 686; exa- mination of in Bright's disease, 823; various kinds of casts in, 824 Urticaria, diagnosis of, 832 ; treatment of, 837 Uterine discharges, microscopic examination of, 100 Uterus, appearance of cancerous juice from the, 101; fibrous structure of the, 189; fatty degen- eration of, after delivery, 256 Vaccination, mode of, 966; Dr. "Wier's scarifica- tor for, 966 Vaginal discharges, microscopic examination ot, 100 Valsalva's treatment of aneurism, 626 Valves of the heart, diseases of, 575 Van der Kolk's observations on phthisical spu- tum, 95; views as to the propagation of cancer, 241 Varicella identical with small-pox, 968 Varicose aneurism, between vena cava and aorta, 217 ; case of communicating with the pulmonary artery, 608 ; signs of, 610; patho- logy and treatment of, 511 Variola, cases of, 962 ; treatment of, 963; obser- vations upon, 965. See Small-pox Varix, 218 Vascular growths, 216; aneurismal, 217 ; erec- tile, 218; varicose, 218; of new vessels, 218 Vegetation, dendritic, 215 1022 INDEX. Velpeau on the propagation of cancer, 239, 242 ; his letter on the results of excision of cancers, 245 Venesection. See blood-letting Ventilation, 326 Vermifuge remedies, 542; male shield fern, 544; kamala, 544 Verruca achrocordon, 107, 212 Vesical calculi, 276 Vesiculae, definition of, 828 ; diagnosis of, 832 ; treatment of, 837 Vessels, auscultation of the large, 74 Villi, formation of, in pericarditis, 175 Vocal resonance, 67 Voluntary motion, 148 . Vomited matters, microscopic examination ot, 97 Vomiting and nausea in phthisis, treatment of, "Warts, 211 "Waxy degeneration, 249 "Weir's vaccinating instrument, 966 Winterich's percussion hammer, 49 Woorari, effects of, 453 Worms, intestinal, 539; varieties in man, 542 Zymosis, definition of the term, 953 NLM032061812