bibition of serum had taken place into the central white substance of the brain, and there was consequently no softening from maceration. The histological changes described in the textures of the brain, are exactly the same as those which I connected with clinical researches into the nature of diseases of the nervous centres, in 1842-3. Since that time it has been supposed by some pathologists that the fawn-coloured softenings are more allied to fatty degenerations than to inflammations. But, notwithstanding the authority of some who have maintained this doctrine, I still believe that it is not a mere fatty metamorphosis, either of the vessels or of the cerebral substance, which occasions the change, but rather a transformation of the exudation, which has been poured forth from the former. Since those researches were published, I have had numerous opportunities also of determining the histological character of indurations of the brain, which have always been seen by me to depend on a firm and finely coagulated exudation, thrown out between the normal elements of the cerebral texture. Within the last two or three years, however, considerable interest has been attached to the corpora amylacea, or amyloid bodies, first noticed by Purkinje and Valentin, and since carefully described and figured by myself in the March No. of this Journal for 1848, p. 661.1 It has now been ascertained, that whilst some of these bodies are essentially a mineral impregnation upon an organic basis, others possess all the reactions of starch or cellulose, and are changed into a beautiful blue on the addition of weak sulphuric acid and a watery solution of iodine. This remarkable fact was discovered by Virchow, and may be considered to be fully established by the subsequent observations of Busk and others. At the commencement of this session, my assistant, Mr Carter, showed me these bodies changed into a beautiful blue by iodine. They had been taken from an indurated tumour in the brain. In the present case the amyloid bodies, although they exactly resembled the appearance of those which are changed blue by iodine, were found to be unaffected by it. The true significance of these curious structures, in their relation to physiology, pathology, and clinical medicine, has yet to be determined. ACUTE ARTICULAR RHEUMATISM-MULTIPLE ABSCESSES IN THE WHAT James Lockie, æt. 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 joints. During the four following days the right wrist and ankle joints were also affected, together with both knee joints. Four days before admission the heart's action became very violent, and leeches were applied to the precordial region. The pain and swelling of the joints have continued since. 1 See also Cancerous and Cancroid Growths, p. 76, figs. 81-84. On admission he complained of great pain in the right wrist, ankle, and left shoulder joints, which were swollen, immoveable, doughy to the feel, tender to the touch, with the integuments over them erythematous. From the left shoulder joint, the swelling extended into the axilla and down the inside of the arm. Pulse 130, full and strong-heart's impulse violent, but no blowing murmur. The tongue coated with brown in the centre and white at the edges-no appetite-great thirst-skin hot and dry-urine turbid from excess of lithates-bowels open-no headache, and the other functions normal. Fiat venesectio ad 3xiv. Potassæ nitratis 3ss. aquæ 3vj. solve.—3ss. to be taken in half a tumblerful of water every four hours-warm saturnine lotions to the inflamed joints. December 2d.-Little change, pulse 120, more soft, blood not buffed, but it was drawn from a small orifice. December 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 3j. 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 diaphoresis. 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 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 manubrium of the sternum, extending up the left side of the neck, which was opened on the 24th. The skin over the heels, trochanter of the right hip, and the sacrum sloughed, notwithstanding every care taken to prevent it. On the 26th, the whole of the right lower extremity was swollen, edematous, and white, resembling in aspect phlegmasia dolens, there was laborious breathing, and great prostration. Low muttering delirium, and involuntary evacuations supervened, and he sank on the morning of the 27th. The treatment had latterly been directed by generous diet and stimuli, to support his strength, relieve pressure on depending parts, and to dressing his sores. Sectio Cadaveris-December 30, 1854.-Body greatly emaciated, a fistulous opening, the size of a shilling, existed immediately in front of the left sterno clavicular articulation. Other sores, varying in size from a half-an-inch to 3 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, infiltrated with putrid pus, a great quantity of which had been evacuated by openings previously 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 communication could be traced between the external and internal abscesses. Brain.-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 inferor lobes of the lungs were condensed. On section they presented a reddish purple colour, the air vesicles filled with a soft sanguineous exudation and readily sinking in water. Heart.-Healthy. Abdomen. Kidneys slightly enlarged-one section presenting a whitish mottled appearance, without great atrophy of the secreting, or encroachment on the tubular substance. Other abdominal organs healthy. Joints. The left sterno-clavicular articulation was carious and disarticulated, with matter burrowing to considerable depths in the surrounding soft textures. The right shoulder, left elbow, right wrist, both hip joints, both knees, and both ankle joints, were filled with dirty purulent looking matter, which, in several instances, more especially in the left elbow and hip-joints, had infiltrated itself more than half way down the fore arm and thigh. The various articular cartilages presented all stages of abrasion, softening and ulceration, whilst the osseous textures below exhibited a curious 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 every where unusually fluid-even in the heart, presenting small, dark and soft coagula. Microscopic Examination.—The pus consisted of molecular and granular matter with debris of disintegrated 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 laminæ of chronic exudation, consisting of dense amorphous matter, principally composed of minute molecules. The blood was carefully examined, and every where found normal. This was a case of what is commonly called pycemia, and is not uncommon from the result of mechanical injuries, or suppurative diseases. I believe it to be very rare, however, following attacks of acute rheumatism, such as all 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 ottorrhoea and abscess in the ear,1 to which he theoretically ascribes the origin of the disease. In the present case there was no primary abscess, no evidence of a preexisting collection of pus before the attack of rheumatism, and I think there can be little doubt that the constitutional state of the blood, whatever that is, was dependent on the abscesses, which resulted from the acute inflammation of the joints. If by pycemia be understood that pus, as pus, enters the bloodin other words, that the corpuscles of that fluid mingle and circulate with those of the blood-the idea is erroneous. Such mingling of pus cells produce no such effects as are witnessed in these cases. In leucocythemia we observe the blood to be loaded with corpuscles, which, in all their physical characters, are identical with those of 1 Practice of Physic, vol. i. p. 372, 3d edition. NEW SERIES-NO. II. FEBRUARY 1855. P pus, and yet none of the supposed obstructions in the smaller vessels, and no multiple abscesses ever occur. Nor when healthy pus is injected into the veins of a living animal, do these results take place, as has been proved by numerous experimenters, and of which I satisfied myself by some careful experiments, performed with Professor Barlow of the Veterinary College of this city. But if by pyœmia be understood a morbid poison generated in pus, which, on its absorp tion, taints the system and leads to the secondary abscesses, then the idea seems to me to be correct. I think, however, it would be better, with Boyer, Bonnet, Darcet, and Bérard, to speak rather of a purulent infection than of a purulent absorption; for direct experiments prove that putrid pus produces the effect that healthy pus does not. Besides, we know that morbid pus of various kinds when absorbed into the system, such as that of small-pox, glanders, syphilis, etc., not only induces the constitutional fever, but tends to the production of secondary collections of pus, whereby the poison is supposed to be eliminated. On the whole, a careful consideration of this difficult subject has led me to the conclusion, that such cases as the one now recorded, are not owing to simple admixture of pus with the blood, or to phlebitis, but to the presence of a peculiar poison which contaminates the system. THE CRACKED POT SOUND (bruit de pot file) IS NOT ALWAYS INDICATIVE OF A CAVERN. On examining a man called John M'Kay, on the 2d of November 1854, it was determined on percussion of the apex of the left lung anteriorly, that it was unusually resonant, and accompanied by distinct cracked pot sound, of a clanging character. On auscultation over the part, the inspiration was harsh and exaggerated, the expiration prolonged, and the vocal resonance very loud, amounting to pectoriloquy. This unusual combination of physical signs attracted my attention. The rest of the lung, as well as the condition of the opposite one, together with the symptoms, could leave little doubt that this man was in the last stage of phthisis pulmonalis. The disease followed its usual progress, both lungs being ultimately affected, and the apex of the left one always presenting on percussion the same physical characters as have just been described, without moist rattle of any kind. He died January 6th, 1855, and on the following day his body was examined. Both lungs were scattered throughout with miliary and infiltrated tubercle, and the intervening pulmonary tissue was loaded here and there with simple exudation. At the apex of the left lung was a mass of bluish-grey miliary tubercles, about the size of a hen's egg, closely condensed together, very hard to the feel, and cutting under the knife with considerable resistance. This mass was solid throughout, tolerably limited, the pulmonary tissue around being light and spongy, con 1 Monthly Journal, January and March, 1853, pp. 80, and 272, 273. taining a very few small isolated tubercles. There was no cavity or softened tubercle in this left lung, although, in the opposite one, a few small anfractuous excavations existed here and there in the upper lobe. 1 According to Skoda, "the cracked pot sound is heard in the thorax, over tolerably large and superficially situated cavities which contain air, and communicate with the bronchial tubes. When the percussion is forcible, or the thoracic walls flexible, the cavity is compressed at each stroke, and a portion of air suddenly driven out of it into the bronchial tubes; this hissing murmur, caused by the escaping air, is mixed up with the ordinary percussion sound of cavities, and this compound represents the cracked pot sound." But the observation made in the case of M'Kay, has satisfied me that occasionally distinct cracked pot sound may be elicited over condensed lung, without any cavity whatever. In referring to an excellent paper on this subject by Dr Markham, I find that on one occasion, both he and Dr Sibson have noticed this phenomenon, over the upper portion of a lung, which was afterwards shown to be gorged with blood and serum, though still retaining some portion of air It would seem, from what has been said by Skoda, Stokes, Walshe, as well as by Dr Markham, that a peculiar tympanitic sound may be heard over collapsed or condensed lungs, when covered or mingled with a certain amount of air. For instance, when in cases of pleuritic exudation, air is effused into the pleura, a few hours before death-when in certain cases of pneumonia there is also emphysema, etc. In the case I have alluded to, these conditions were so far fulfilled, that the tubercular mass described was surrounded by spongy lung full of air. At all events, it must be evident, that the physical conditions on which this peculiar sound depends, require more careful study, and that our ideas as to its necessary connection with a cavity, must undergo modification. TRIAL OF PHOSPHORUS IN PARAPLEGIA. I have given phosphorus in seven cases of paraplegia from disease of the spinal cord, in the form of phosphuretted oil (4 gr. of phosphorus dissolved in 3j of olive oil.) In none of these cases have I been able to satisfy myself that any improvement 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 in doses of three drops. In the case of chronic myelitis, which took ten and fifteen drops, the phosphorus was excreted by the lungs, as the breath smelt strongly of the drug, but was not phosphorescent at night-a phenomenon which has been seen by some physicians who have employed it. In 1 Markham's translation, p. 21. 2 Monthly Journal for June 1853, p. 495. |