PROVINCIAL MEDICAL & SURGICAL JOURNAL. THE LAW OF THE MORPHOLOGY OR META- (Fourth Series of Experimental Researches.) By WILLIAM ADDISON, M.D., F.R.S., Malvern. (Continued from page 120.) IX. SCROFUla. If the lineaments of the face, the colour of the eyes and hair, the tones of the voice, an ear for music, and mental aptitude, be handed down from father to son, they must be so by a wonderful consentaneous harmony of organization—an almost incredible conformability in the morphology of nutrition; and if the physiology, if the constitution, temperament and mind, be so similar, then, however little we may be able to explain the fact, it follows almost necessarily that the pathology and diseases will prove so too;not scrofulous diseases exclusively, but all others also. "The most certain evidence of the existence of a scrofulous disease," observes a recent medical writer, "is afforded by the production of a soft brittle unorganized matter, resembling curd or new cheese, which is found mixed with the contents of abscesses, or deposited in rounded masses of different degrees of firmness, and varying in bulk from the size of a millet seed to that of a hen's egg; sometimes it is enclosed in cysts, and occasionally it is diffused, as if by infiltration, through the natural texture of the part. To the rounded masses of this substance the name of tubercle has been assigned, and the substance itself has been named tuberculous matter." X. SEAT AND NATURE OF TUBERCLES IN THE Scrofula is the term used to designate a particular state or condition of the living body, rendered apparent by the phenomena of its nutrition and diseases. The term, whatever may have been its origin, seems like many others in medical science, to have been handed down with reference to the human structure for convenience sake, rather than for any other reason. Writers upon the subject of scrofula, for the most part, reiterate one after another certain external appearances in the general contour of the person-in the eyes, lips, nose, countenance, or complexion, by which they say those individuals who are scrofulous may be distinguished from others who are not so. But we shall hereafter shew that no satisfactory practical distinctions can be safely made upon such grounds, the constitutional disposition not declaring itself until the qualities of the textures, and their capacity of withstanding injurious iufluences, have been tested and declared by some irritating or disturbing cause, giving rise to an unusual local increase of nutritive matter; when the form of the morphology or metamorphosis-the conformable or unconformable type of the changes-pronounces the constitutional diathesis. If there be one fact better established than others in respect of scrofula and scrofulous diseases, it is their hereditary character, the offspring exhibiting bodily and mental powers, and forms of disease similar and analogous to those which have been known to exist previously in one or both parents. This transmission of structural or constitutional and other qualities, from parent to child, is one of those rezmarkable facts in living bodies, which we look to the recent rapid advances of physiological science to elucidate. To say that children inherit the dispositions and diseases of their parents, and to rest content with the barren assertion, is to leave to conjecture questions of the highest interest to medical and moral science. p. 701, Art, Scrofula. No. 7, April 7, 1847. Tubercular consumption and phthisis are terms used to designate that species of disease which consists in the filling up of the air-cells of the lungs, and the destruction of their vascular walls by a soft, brittle, white matter, named tubercle or tuberculons matter. The best and most recent pathologists have differed in their statements and opinions regarding the seat and nature of tubercles in the lungs, nor are they agreed as to the changes they undergo. LAENNEC describes them as small firm bodies, which gradually enlarge, then soften, and by degrees become converted into a liquid mass. ANDRAL differs somewhat from Laennec, he says that tubercles soften, not from any spontaneous changes in themselves, but from an admixture of purulent matter poured out from the living texture immediately surrounding them. Dr. CARSWELL states that • Dr Cumin in Cyclopædia of Practical Médicine, Vol, 3, tubercles originate from morbid changes in the blood, and the texture, from the various blendings of the red and that their most frequent seat is the surface of the colour of the blood with the white colour of the new mucous membranes; this author believing, in com-material separated from it, assumes various hues mon with many others, that the membrane of the air-between dark red and whitish yellow. cells of the lungs is a mucous membrane. Dr. C. J. B. WILLIAMS states that "lymph, pus, and tubercle, pass by imperceptible gradations into each other;" and in this opinion I concur, in so far as that pus may pass into tubercle or mucus, or into a mixture of tuberculous and mucous matter, but the converse never can occur. Tubercles exist in the lungs more frequently than is generally imagined. Of the numerous apparently healthy lungs which I have examined in the course of my researches, I have found them in about one-third. | In their early state they escape notice, unless searched for with a lens in very thin sections, gently extended upon a dark back-ground. In order to make out correctly the primary situation of a tubercle, the examination should be made in the lungs of young persons who have died of other diseases; for in those who die of consumption, so many changes have taken place, and the several textures of the lungs have been so altered, that it is impossible to find tubercles in that early condition in which alone their situation, in or upon the membrane of the air-cells, can be determined. I have repeatedly examined with the microscope the material deposited in the air-cells of the lungs in pneumonia, and compared its characters and appearance with that forming a tubercle, without being able to detect any more essential or constant difference between them, than exists between recently excreted and old pus. The same class of objects,-incoherent colourless cells, molecules, and granular matter, appears to constitute the material in both cases,in hepatization or consolidation of the lung from inflammation, and in consolidation from tuberculous matter; and in both cases also the material takes primarily the shape of the air-cells in which it is seated. In the material forming the consolidation resulting from inflammation, incoherent cellular forms predominate, as they do in recent pus; whereas in tuberculous matter, granular masses and molecules greatly predominate, as is also the case in old pus. And were we to imagine the fluid element of old pus removed or absorbed, the remaining solid matter would be, in my opinion, tuberculous matter; the colourless elements of blood, pus, and tubercle passing by imperceptible gradations into each other.* In pneumonia the consolidating material is as it were suddenly thrown out over a wide extent of lung All the blood-vessels are loaded with colourless elements. The blood itself when withdrawn assumes a buffy coat, By the term old pus, the reader will understand that I mean matter which has been a long time excreted, and in which the corpuscles or cells having broken down, there remains a thick, more or less fluid material, composed of granular forms and molecules, In phthisis, on the other hand, the consolidating material is deposited at distant points, in a much slower manner; it becomes as it were old before it becomes visible, and I have seen sections of the lung display an appearance precisely analogous, and indeed very similar to that of the face in small pox, and this in a patient who did not die of consumption. My researches have been in like manner extended to the characters and appearances presented under the microscope by the material taken from pimples, boils, and all kinds of eruptions on the skin, and in all these instances incoherent colourless cells, granular matter, and molecules, have been found in the greatest abundance. Moreover-and it is a fact of much importancethe same objects have been profusely detected, not only in the fixed textures surrounding the morbid matter, but likewise in blood taken from the vessels administering to their nutrition. And it would appear that when any texture becomes involved in a hurtful or destructive inflammation, or in a tuberculous or scrofulous disease, that its physiological type is altered and its function impaired; the structural elements, whatever may be their normal qualities or characters, become more and more uniform, and at length corpuscular, the corpuscles being apparently identical with those circulating in the blood. It has been said that tubercles arise from "an error of nutrition," which is perfectly true, but no practical advantage is derived from the use of a few words which are applicable alike to all diseases. XI. STRUCTURAL CHANGES PRODUCED BY SCROFULOUS DISEASE. A woman, aged 34 years, died of scrofulous disease of the bones and consumption. The body was examined a few hours after death. Four sinuous canals with external thickened outlets, discharging mucus, lymph, and clotted pus, existed on the right shoulder, leading down to diseased bone and other textures at the joint. Another sinus passed through the breast bone into the fibrous or areolar texture beneath it, entering the anterior mediastinum. internal surfaces of all these sinuses were excreting incoherent cellular forms, and when closely examined The with a lens, were found red and vascular, covered with muco-purulent matter, mixed with clots and white flakes. The clots and white flakes examined with the microscope were found to be incoherent, cellular, or corpuscular textures. On opening the chest, the sinus passing through the breast bone was found traversing, by various channels, the areolar texture of the anterior mediastinum, which was extensively changed in character and appearance; it was much thickened, much more red and vascular, ON VARICOSE VEINS. 400 and the new anormal vessels and textures had evidently The lungs externally were of a deep purplish slate 171 Fig. IV-A larger vessel in the areolar texture, (normal.) Fig. V.-Vessels excreting pus and mucus, from a scrofulous sinus in the areolar texture of anterior mediastinum. Case 1. The textures were not tough, coherent, and elastic, but soft, and very brittle; and it was only here and there that the waved and tortuous filaments, copiously found in all the minute vessels traversing the areolar texture of the healthy lung, could be discovered. (To be continued.) ON VARICOSE VEINS AND THE ULCERS By JOHN M. BANNER, Esq. Senior Surgeon to the Northern Hospital, Liverpool. There are few diseases more painful or distressing in every point of view than ulcers dependent on a varicose state of the veins, and there are few diseases which have occupied the attention of the profession more than this. Much has been written, and many are the Fig. III-A capilliary vessel in the fibrous or areclar modes of treatment recommended. During the period texture, (normal,) that I was a pupil and house-surgeon at St. George's Hospital, which extended over the year 1818 and to the end of 1823, more than an ordinary degree of interest existed on the part of the surgeons of that Institution in the treatment of this disease. During that time the ligature was applied to the vena saphena, a portion of the vein was cut away, and a division of the vein was also effected by cutting. Such indeed was the interest excited that we severally partook of it. The same interest has continued with me up to the present day; and from the writings and lectures of Sir B. Brodie, we may conclude that it has continued with him also. The energy and persevering industry of Sir B. Brodie has ever been so great that we cannot feel surprised that he has continued, with unabated ardour, his endeavours to master this troublesome disease, as he has done in innumerable other instances. My interest in this ailment has led me to watch the various means recommended for its cure or alleviation. I have in many instances tested their value. It is the results that I wish to bring before the profession, and though in several of the modes of treatment, from their very marked unsuccessful issue, I have been held back from trying them so fully as I could have wished, where the plan has succeeded in my hands, I have given it a full and fair trial; where it has not done so, or where it has failed in the hands of others, I have contented myself with giving extracts from the writings of those who advocate it. I am unprepared to offer anything new on the pathology of the disease; nevertheless, I have thought it well, before entering on the treatment, to draw attention to certain selections which I have made from distinguished writers, on the pathology and other matters connected with it; this I do without apology, as I consider they will prove of advantage in the contemplation of the subject. varicose vein in a living person, the blood is seen to spout from the upper end, as it does from an artery. 2nd. In those persons in whom varices have been caused by wearing tight garters under the knee, the veins are remarked to be more distended above the band than below it. 3rd. When the operation for varix is performed, either by the ligature or excision, those varices which are situated below the ligature or excision, are seen to contract and finally disappear, whilst those situated above remain stationary or increase, which would not be the case if the blood in these vessels flowed, as it usually does, from below upwards, as the weight of the column of blood from above acts in such a manner as to paralyze the valves of the veins, and thus keep up the communication between the individual varices. 4th. The pathological anatomy of varicose veins exhibits, in the lower extremities, hypertrophy of the walls, and a structure like that of the arteries. He thinks that inflammation following on a passive dilatation of the weak venous parietes between every two valves, with the weight of the column of blood from above, may be the cause of this hypertrophy; from this, chronic inflammation and thickening follows, and a change of structure. Andral specifies several varieties of the disease :1st. Simple dilatation of the veins, without any other alteration, and either extending all along the vessels, or confined to particular points of them. 2nd. Dilatation of the veins, attended with a thinner state of their coats, and it may be either an uniform, or an irregular dilatation. 3rd. Uniform dilatation, with thickening of the coats of the veins. 4th. Dilatation, with thickening of the coats and interspaces between the varicose enlargements. In the two latter cases, as the vessel increases in diameter, it also becomes elongated and tortuous. This is the ordinary form of varices. 5th. Septa or partitions are formed in the vein, whereby its cavity is divided into small cells, in which the blood accumulates and coagulates. The late Sir Astley Cooper, in speaking of this condition of the veins, remarks that it may arise from a variety of causes; the more immediate one is either a thickening of the valves, so that they are incapable of approximating, or a rupture of the valves. In either case the effects will be the same; the blood pressing in one uninterrupted column, the veins become distended and serpentine, and the valves widely separated from each other; their arteries by their powerful attempts" to return the blood to the heart soon excite inflammation. This opinion appears to have been adopted by several other surgeons. Signor Rima, the Surgeon-in-Chief of the Hospital at Venice, in his "Treatise on the Proximate Cause of Varicose Tumours in the Lower Extremities," states that the real proximate cause is a reflux-motion of the blood in the veins, for instance, the blood from the femoral vein retreats into the saphena, and is driven backwards from the groin towards the foot, by a power peculiar to these veins. He comes to this conclusion from the following facts: 1st. When a surgeon removes a portion from a 6th. In the last form of varix, described by Andral, from careful dissections, there are, in addition to the disposition exhibited in the fifth variety, various irregular perforations in the sides of the vein, and the vessel thus communicates with the surrounding cellular membrane, which is generally more or less diseased, as is exemplified in hæmorrhoids." Mr. Syme, of Edinburgh, enumerates tall stature and largeness of the veins, as predisposing to this disease; constipation, pregnancy, and sedentary occupation, favour its actual commencement. Sir Everard Home observed, that in the army the grenadier companies are especially subject to varicose veins. Sir B. Brodie remarks that cooks are very liable to this diseased state of the veins, and enumerates certain exertions as liable to produce it, and remarks the seventh month, when the limbs resumed their natural that he has known a few instances where the varicose | appearance, and continued perfectly well until the lady state of the veins appeared immediately after hard walking. Professor Cooper enumerates tall stature, large size, a long perpendicular course of the veins, as predisposing causes to the disease. It appears to me that there must exist a predisposition to this disease in the person affected,-some peculiarity in the structure of the veins,-my experience does not bear out the observations of several writers, that persons of tall stature and large frame are the most liable to this disease. I have remarked that those of short stature and spare habit are also much affected with When Sir Everard Home stated that the grenadier companies are very liable to varices, he should have added also, that soldiers are subject to hard walking, which is given as a cause of this disease by Sir B. Brodie, and that they, in the days of Sir E. Home, wore the garter and knee-breeches, which, according to Signor Rima and Sir B. Brodie excite the varices. In the many cases which have come under my care, I have found that those who have undergone severe exercise of the lower limbs, whether they be tall or whether they be short, have been the subjects of this disease, and have had occasion to remark that many of the footmen in London are subject to it, those more particularly who were required to show a good leg and had to stand many hours together poised on the toes behind carriages. These men garter tightly, and where the predisposition existed, the practice no doubt acted as an exciting cause. Those subject to an exposure to great heat (as for instance cooks and foundry men,) I | have observed are very liable to it. What is it then that causes this predisposition? According to Sir B. Brodie, the disease has been produced immediately after hard walking, proving at once that the coats of the veins were weak and easily dilated, or that the valves were defective; and the fact that many of the persons afflicted, have one vena saphena only diseased, proves that tallness of stature, largeness, and heat, do not entirely produce the disease. And again, many hundreds under exactly the same influences, escape the disease, which to my mind would at once prove a predisposition to it in certain individuals, which from an excitant developes itself. Women having children are subject to an enlargement of the saphena and its branches; in the several cases which I have met with, the varices disappeared at the seventh month of parturition, proving that the diseased state before alluded to did not exist. I recollect one case in particular in which a lady was seized suddenly at the fourth month of pregnancy with great pain and stiffness in the legs. On examining them I found the superficial veins generally distended, and the limbs presented a bluish appearance; the feet were cold. In this case the veins were not tortuous nor knotty; they felt generally distended. This state continued until was again four months advanced with child, the varices then re-appeared, and disappeared as usual at the seventh month. This effect has been produced on four successive occasions, and in every instance the result has been the same. I have met with three similar instances. I fancy that when Andral enumerates a simple dilatation of the veins as a variety of this disease, he must allude to such an instance as those I have referred to, and which can scarcely be considered a true state of varix. That there is some peculiar predisposition to this disease is manifest from the fact that it very frequently happens that the saphena vein in one limb is alone affected, which would scarcely be the case if it depended only on the causes enumerated. A patient came under my care in whom there was a large cluster of varicose veins on the inside of one knee, forming a tumour as large as an egg, which she stated came suddenly during parturition, and has continued slightly increasing for eight years. This is the only part affected. The veins most liable to become varicose are the spermatic, hæmorrhoidal, and saphena. These veins, from the peculiarity of their situations, are liable to be acted on by pressure, therefore we may conclude that pressure has much to do in rendering them distended, knotty, and tortuous. I am not prepared to state what the exact condition of the vein may be prior to the varicose state; there can be no doubt that a diseased action exists, most probably in the valves. We seldom have our attention drawn to the stage of the complaint alluded to; when applied to we usually find the vein tortuous and enlarged, accompanied with an ulcer in the leg, and where we have an opportunity of examining the parts after death, we find the vein enlarged, elongated, and thickened, more generally thickened at interspaces. In some instances the coats are unnaturally thin, in others the valves are widely separated; in some they appear too small for the calibre of the vessel, and occasionally we find them ruptured. The superficial veins are, in almost every case, considerably enlarged. In contemplating the various modes of treatment which have been adopted by those writers who have distinguished themselves for their laborious researches and high attainments, we may conclude that the essential object they have each had in view has been the most efficacious means of partially or entirely destroying the vena saphena. The ulcer dependent on a varicose state of the vein has appeared to them only permanently curable, through the partial or entire destruction of the vein. This appears to have been the object of Sir Everard Home, Sir B. Brodie, MM. Fricke, Velpeau, Davat, Sanson, Bonnet, and others. Sir B. Brodie has devoted much time and attention to this disease, |