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OF THE TEXTURES.

It must be borne in mind that the inflammatory process in some forms of phlebitis does not pass beyond the deposit of the plastic lymph, and that no farther morbid change taking place, the blood escapes that fearful purulent contamination, which, if once established, rarely terminates otherwise than fatally.

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You must bear in mind, however, that the absence of these general symptoms is not to be taken as an index, that little is required to be done, or that the case is trivial, and needs but slight attention. So long as the vein is the seat of inflammatory action, so long as a fibrinous deposit clogs up the canal, suppuration of the

in obedience to the organic laws governing these pathological products. It must be our object, therefore, in the treatment of such cases, to avert if possible this much dreaded mode of termination. This can only be effected by the judicious and persevering application of those remedies that have been already indicated. The period of convalescence must be treated with caution; there is a special tendency to relapse in these cases; the local inflammation then re-appears with an intensity that no remedies can check, and which now passes rapidly and uncontrollably into purulent transformation and inevitable death.

The case we have just seen presents us with an plastic mass may be dreaded, not remotely, not continexample of an exemption from these terrible second-gently, not merely accidentally, but as a change strictly ary consequences; you must, nevertheless, not forget that however trivial and light the symptoms may have appeared to you, a case of inflammation of the veins from whatever cause, must be considered serious, as the tendency to purulent degeneration of the plastic mass is greater than either to its solution, removal, or semi-organization. When purulent transformation of the deposited lymph does not take place, it is often remarkable with what rapidity the plug disappears, and the function of the vein as a permeable tube is restored. In the case under consideration, in the course of a few days, the vein had become soft, and evidently permeable. Hasse states that this change is effected probably by the liquefaction and solution of the plastic mass in the circulating fluid, and a channel by this means is again opened to the sanguineous current, and there are many reasons for supposing that the exuded lymph is not removed by absorption by the vasa vasorum, but is absolutely dissolved in the blood, and carried away into the general circulation. The removal of the fibrinous deposit in this case, and the subsidence of all farther symptoms of inflammation, were consentaneous with the faint indications of ptyalism produced by the small and alterative doses of mercury. From this moment the cord-like hardness disappeared, the veins in the greater portion of their course had become soft and elastic, while the dusky line which marked the course of the inflamed vessel had entirely disappeared.

The rheumatic diathesis does not often express itself by phlebitis; yet it is not difficult to understand, that in certain morbid conditions in which the fibrinous elements of the blood are in excess, and a general inflammatory predisposition exists, cold locally and continuously applied to the lower extremities, in a manner favourable to local derangement, may predispose to inflammation of the veins of those parts. There must, however, be a special idiosyncrasy to determine the inflammatory action to the venous tissues, rather than to the fibrous tissues, muscles, ligaments, tendons, or synovial membranes, as is most frequently observed in rheumatic inflammation. In fine, this case teaches us, that under special circumstances, exposure to cold and damp, acting on the rheumatic diathesis, is to be considered among the predisposing causes of idiopathic phlebitis; and that though rarely developing this disease, yet under favourable circumstances, and in peculiar idiosyncracies, these causes are competent to call it forth in its mildest, as well as in its most formidable, aspects.

THE LAW OF THE MORPHOLOGY OR META-
MORPHOSIS OF THE TEXTURES OF THE
HUMAN BODY.

(Fourth Series of Experimental Researches.) By WILLIAM ADDISON, M.D., F.R.S., Malvern. XI. STRUCTURAL CHANGES PRODUCED

BY

Phlebitis in all its forms presents us at the outset with all the characteristics of a sthenic inflammation, and the treatment must be based on those principles which experience teaches us are most successful in arresting the results of inflammatory action. A general antiphlogistic regimen must be strictly enforced. Mercurials, with opium, or Dover's powder, are the best alteratives. The lower extremities of this patient were for nearly four days enveloped in hot moist flannels, constantly renewed. The best results have followed this treatment; the patient is convalescent, and the hardened plastic deposit in the saphena veins has nearly disappeared. The amount of constitutional disturbance was but slight; beyond the appearance that the countenance indicated of deranged health, there was no symptom of any moment declaring that the general functions of the chylo-poietic viscera were much deranged; the appetite was not deficient; the bowels not irregular; but the urine was loaded with urates, uric acid crystals were also apparent, and there was a considerable amount of purpurine in combination. From the absence of much constitutional disturb-healthy lung; it was converted into an ash-grey coloured firm texture, which did not in the least ance, it would appear from this example, that it is not till the terrible condition of purulent degeneration of degree collapse upon the opening of the chest, but the plastic lymph has commenced, that any remarkable remained bulging upward, filling the whole of the or characteristic constitutional symptoms are developed. I right cavity of the chest, and adhering firmly at all

SCROFULOUS DISEASE.
(Continued from page 171.)

A man, aged 37 years, died of hæmoptysis and phthisis. The body was examined forty-eight hours

afterwards.

On opening the chest, the right lung was immediately seen to be totally different from anything resembling a

On making sections into the right lung, the normal texture of the organ could no where be found, the whole of it having been transformed into the brittle ash-grey substance before-mentioned. This new and

points to the costal wall. On attempting to separate the adhesions, the texture composing the lung was found extremely brittle, crumbling down under the fingers like dry gingerbread, and every now and then a cavity containing pus,-soraetimes white and some-morbid texture was internally partly red, and partly times red,-was opened by the separation. The pleura in the first place was found altered in vascularity and appearance; it was very much thickened by innumerable layers of a fibrous texture, infiltrated with transparent gelatinous (mucous) matter. The fibres were seen by a lens to be curled or waved, and elastic; in the direction of their length several red vessels traversed between and among them, and their minute branches extended into, and subdivided in, the gelatinous material. The arrangement and size of the vessels in one layer of this fibro-gelatinous texture, bore no resemblance to those of another layer, and in all it differed essentially from the mode of distribution of the vessels of the healthy pleura. In one of these fibro-gelatinous layers I counted with the lens fifteen vessels, pretty nearly equal in size, running side by side a straight or parallel course of an inch or more, without giving off any branches, or receding from, or approaching nearer to, each other; their internal diameters varied from th toth of an inch, and they were distant from each other, about theth. The intervals between the vessels, including the walls of two contiguous vessels, consisted of glistening waved fibres, imbedded in gelatinous matter. Under the microscope this gelatinous or mucus-like matter, the relations of which have been traced in former researches, had the appearance of a fibrous texture, thickly studded with colourless cells; and the red vessels traversing it had no other coats or walls than what were formed by the material itself.

white or grey, both portions containing numerous cavities; those situated in the red parts differing, however, in many particulars, from those situated in the white or grey. The free surface of the walls of the former,-the red, for instance,-was smooth and uniform, covered with a soft, pultaceous, white material, beneath which were large straggling red vessels, visible to the naked eye, ramifying in all directions. The free surface of the walls of the cavities in the white substance was very rough, resembling a miniature rockwork, irregular eminences and projections, and sometimes bands, thrusting out on all sides, partially dividing the cavity into numerous compartments. These irregular walls were here and there reddened in patches by blood-vessels, but altogether the vascularity was much less than upon the smooth walls of the cavities in the red texture. The substance of the lung, wheresoever small portions were examined with the microscope,-whether in the whiter, or as Dr. Williams describes it, parsnip-coloured, portion, or in the red,— was found, composed of colourless cells, granular matter, and molecules. The white pultaceous matter lining the surface of the cavities in the red portions of the structure, was a corpuscular or incoherent cellular texture, (nearly solid pus,) and the coats of all the minute blood-vessels which were examined with high magnifying power, were found chiefly or entirely composed of similar objects or cells.

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Fig. VI-A blood vessel, from abnormal fibro-gelatinous texture, on the surface of scrofulous lung.-Case 2,

A girl, aged fifteen years, was seen but once, lying in bed upon the left side, with the knees drawn nearly up to the chin; the eyes were suffused with tears, and the conjunctiva red; the pulse was feeble and quick, the tongue red and dry, and she complained of headache; there was a slight squint in the left eye, and upon trial the left hand and arm were found weaker than the right. These last two symptoms it was supposed were new or recent, for upon inquiry they had not been noticed before. Upon farther investigation it was found that the illness commenced two months before with influenza, cough, and pain in the side; these symptoms subsided in about three weeks, but as she remained ill, it was supposed, by those previously attending her, that she laboured under an attack of bilious or typhus fever. Two hours after the visit I have just described, the patient was seized with convulsions, and died the following day comatose. The body was examined twelve hours after death.

The pia mater was extremely red, all the vessels being turgid with blood. On examining the vessels through a lens, a number of red nodules or points were seen situated upon many of the smaller branches, beyond which the branch was empty of red blood. [In the subsequent microscopical examination it was forgotten to observe what these red points and the apparent obstruction of the calibre of the vessels was owing to.] Numerous semi-transparent granulations were scattered over the texture. The ventricles of the brain contained a considerable quantity of clear limpid fluid, and the fornix and other contiguous parts of the structure were softened. The plexus choroides was very pale and voluminous, and four or five hydatidlike or vesicular-looking bodies, as large as small peas, were adherent to the structure, the pale colour of which strongly contrasted with the highly injected vessels of the velum or fold of pia mater with which it is continuous.

The semi-transparent granulations of the pia mater were found, on examination with the microscope, to be composed of a corpuscular or cellular texture, and gelatinous matter, and the coats of a small vessel from an opaque portion of the pia mater, appeared to have the same composition. The pallor of the plexus choroides was found owing to an unusual abundance of the large colourless corpuscles or cells, natural to the texture, and the hydatid-like bodies were groups of similar cells. The softened portions of the brain were composed of multitudes of incoherent cells, resembling pus-cells, which had replaced the nervetubes, and destroyed the normal firmness and consistency of the structure.

On opening the chest numerous large red vessels were seen branching over the pericardium, and the interior of the pericardium was found rough throughout to the touch from multitudes of small granulations. The right lung contained many tubercles, and the left lung

adhered to the walls of the chest. The adhesions were very brittle, and when broken down, which they easily were, the surface of the pleura, both on the lung and on the chest, was found rough from granulations similar to those within the pericardium.

Upon examination with the microscope, incoherent colourless cells, and but slightly coherent corpuscular or cellular textures, were found to be the chief and characteristic elements of the granulations, of the soft matter of the adhesions, and of the walls of the minute branches of the new vessels."

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Fig. IX.-A blood-vessel of the same size as Fig. 8, from an opaque spot of pia mater. Case 3.

Other cases, of which I have notes and illustrations,

might have been added to these, but as they all bear upon the same point,-the replacement of the normal elements of the structure by incoherent cellular forms,

In making these microscopic examinations, I remove

small portions of the textures with as much blood as can be preserved in the vessels, immersing them in a weak solution of salt and water. In this way they may be kept full of blood for some hours, and when the small vessels are examined, the red cells may be seen flowing along them, rendering the parts more distinct,

and gelatinous or tuberculous matter, and are all,
therefore, similar to one another-I have deemed the
three cases related sufficient to establish the facts upon
which my conclusions are grounded; and it appears to
me that no one is entitled to disclaim against the con-
clusions, on the presumption that my microscope is
a bad one, or that my eyes see more than other peoples,
and at the same time decline to inform me of the
truth. It seems hopeless to attempt to make any pro-
gress in the knowledge of disease, if, contrary to the
rules by which experimental researches are estimated
in other sciences, it be allowable in physiology and
pathology for any nameless we to dogmatize, without
offering any evidence to shew that work has been done,
and different facts arrived at upon the same subject.
However copious and extensive a man's scientific
knowledge may be, and however much or long he may
have used the microscope on other topics of investiga-venous blood in contact with the air.”*
tion, he derives from these sources no ground of
authority to pronounce judgment, either for or against
my facts, inferences, or conclusions.

But the case is different in respect of the cavities; theyTM
extend into the prominences on the surface of these,
and ramify abundantly in, and impress colour upon,
the bands so frequently stretched from one point to
another of their parietes. If a portion of the wall of a
cavity be placed under water, after all mucous and puru.
lent matter has been washed from its surface, this surface
is seen studded over with tufts of new vessels, which,
taken together, represent a sort of villous structure, as
observed with a common lens. "Hence," observes
the author, M. GUILLOT, "it is not only the highly
vascular network surroundiag the cavities with its new
circulation, that constitutes a striking feature in the
anatomy of these excavations, but farther, the terminal
tufts or villi which bring arterial blood derived from
the aortic circulation into contact with the air, having
replaced the normal capillaries which before brought

Now, the first conclusion which it appears to me may at once be drawn from these pathological researches is, that the deposit of tubercles, or of tuberculous matter, either in the parenchyma of the lung, or in the texture of any other organ, does not explain the pathology of consumption, or of scrofulous disease in general. This corresponds with the fact, now well known, that tubercles may exist to a considerable extent in the lungs, and yet no consumption follows. Tubercles and phthisis have not the relation of antecedent and consequent. These investigations, on the other hand, disclose a vast scene of activity,-new textures, new bloodvessels, new elements, and a busy scene of excretion, amidst which the normal texture disappears, and the natural functions of the organ therefore necessarily

cease.

The researches of SHROEDER VAN DER KOLK, and more especially those of M. NATALIS GUILLOT, have shown that a great transformation in the vascular system of the lungs is one of the remarkable phenomena attending the evolution of phthisis. The injections, dissections, and microscopical examinations of the latter especially, have shewn that as the capillaries of the walls of the air-cells, and the branches of the pulmonary artery supplying them, are obliterated, they are replaced by an adventitious vascular system, supplied not with dark and venous blood, but with arterial, derived from the bronchial arteries, and from the vessels of the mucous texture of the air-tubes. In proportion as the tubercles enlarge and soften, this new vascular system spreads more and more, replacing the branches of the pulmonary artery, until their existence

My microscopical investigations not only corroborate these prior researches, which appear to me to have been strangely neglected, but I think they go farther, and prove that this great vascular transformation is only one of the accompaniments of a great metamorphosis of the pulmonary textures, in which a coherent, elastic and homogeneous cellular texture, with nonsecreting capillaries, is supplanted by a brittle, soft, corpuscular texture, with new vessels copiously excreting or discharging corpuscular or cellular forms.

But it has been proved from a minute examination of the condition of the embryo textures, and of the nature and composition of blood, that the law or order of the metamorphosis in the normal growth of the structure is from incoherent corpuscles containing a secreted material, to soft and brittle corpuscular secreting textures, and from these to the coherent, non-secreting, cellular and fibrous; and therefore, if a coherent, cellular, and fibrous non-secreting texture becomes changed into a brittle corpuscular secreting one, the metamorphosis is retro-grade.† Whether the incoherent corpuscles or cells, which are the distinctive elements of the new textures and of the coats or walls of the new vessels, and which so abundantly appear in the matter excreted or discharged from them, be the identical colourless cells which previously circulated in the blood, or whether they spring by a species of secondary growth from germs in the morbid texture, is a question that need not now be entered on. It is sufficient for the conclusion just stated that incoherent colourless corpuscles, whether springing from the texture or the blood, with very thin and tender

• See Observationes Anatomico Pathologici, &c., of SHROEDER VAN DER KOLK, L'Experience, tom. i., p. 545; and Researches on Phthisis, by Louis, Syd. Soc. Ed.

+ The terms secreting and non-secreting are used here in compliance with the common usage, but in all cases it is corpuscles or cells that secrete the blood-vessels, and textures excrete; the former prepare or elaborate, the latte

ceases to be matter of demonstration. These new-
formed vessels, which at a certain period of the disease
become incalculably numerous, stop short around the
tubercles, without penetrating into their substance.throw off or discharge,

ON HERNIA, AND ITS TREATMENT BY OPIUM.

walls, filled with an elaborated or secreted matter and -molecules, and analogous to those seen in the embryo textures, have taken the place of the transparent, coherent, strong and elastic, cellular and fibrous textures. All that need be affirmed is, that corpuscles or cells, apparently identical with those which form the elements of, and are excreted by, the morbid texture, circulate abundantly in the blood, and may be seen adhering to, and altering the character of, nutrient vessels; and these facts, established by observation and experiment, are sufficient to explain the origin of the elements which effect the structural changes.

But before this conclusion can be admitted as the basis of the pathology of scrofulous diseases, it is necessary that its foundation on natural laws be substantiated by further investigation.

(To be continued.)

OBSERVATIONS ON HERNIA, AND ITS

TREATMENT BY OPIUM.

By BUTLER Lane, M.D., M.R.C.S.E., &c. &c. Among the most serious emergencies of surgical practice may be reckoned cases of strangulated hernia. This is especially the case in country practice, where there may be lack of counsel to impart confidence in action, and where life may depend on the judgment and energy of a single professional individual. Even in the metropolis, where abundant experience and operative skill are available, it must be acknowleged, that such cases often occasion considerable embarrassment. It has always been an object of surgical science to supersede the necessity of operation, in cases of strangulated hernia; other objectionable circumstances besides the danger, place the operation in question among the foremost of the opprobria medicinæ. I am therefore induced to direct the attention of the profession to a method of treatment, which has been attended with such marked success in two consecutive instances, as to convince me that it deserves a fair and extensive trial in the arena of hospital practice.

The plan I am about to advocate, consists in narcotising the patient by the free and continuous administration of opium. Where or with whom this method of treatment originated, I know not, but I shall be happy to surrender the merit of suggestion to any just claimant. When I adopted the practice in the first instance, I had a vague idea of having seen the use of opium in hernia mentioned in some periodical, and my memory did not serve me farther; but from considerations, hereafter to be mentioned, it seemed to me feasible in affording some prospect of relief.

203

had existed for some time previous to the present period. She was under the care of Messrs. Shelley and Stilwell, of Epsom, to whom I am indebted for most of the following particulars; and when I saw her with those gentlemen, unequivocal symptoms of strangulation of the hernial tumour had existed at least three days. The swelling had enlarged considerably, there was much abdominal pain and tenderness, obstinate constipation, constant nausea, and copious vomiting of decidedly stercoraceous character. The symptoms had suddenly supervened, and gradually increased in intensity. In the first instance, the stomach had retained large doses of cathartic medicine, castor oil, and calomel, though without any aperient effect, but now everything was rejected as soon as swallowed. All the usual medical means available had been unsuccessfully resorted to, and the taxis had been carefully and repeatedly applied. The tumour had now become exceedingly tender, the countenance assumed an anxious expression, and the pulse was accelerated. There could be no doubt that the operation was desirable, and that without delay, but to persuade the woman to submit to it was impracticable. I again employed the taxis unavailingly. A cathartic enema was then ordered, and any farther procedure was remitted till the following morning, when we hoped by other means to induce the woman to undergo the necessary operation.

When I again met Mr. Shelley and Mr. Stilwell, we found all the symptoms had increased in urgency, and the vital prostration was become more obvious. Our patient, however, was no less refractory and obstinate than heretofore. Her danger was imminent, and in fact, death seemed almost inevitable. The state of depression rendered a tobacco enema objectionable; it was, however, agreed to try it, but though its sedative influence was fearfully powerful, yet it did not seem to afford any advantage, no fæcal evacuation being obtained, and the stercoraceous vomiting and other symptoms continuing as before. As a last resource, I then suggested the administration of opium, in doses of one grain every hour, which was agreed to, though with but little anticipation of effectual relief.

I saw the woman next day with Mr. Stilwell, and was agreeably surprised at the change which had taken place. Twelve doses of opium had been administered and she was fairly under its influence, having the appearance of a helpless state of intoxication. She had slept much, and when roused, her answers and conversation were very incoherent. The pulse had increased in power, and diminished in frequency. No The first case to which I shall refer, was one of complaint was made of abdominal pain, and there was oblique inguinal hernia, occurring in a female, about much less tenderness in the umbilical region and the 45 years of age. The previous history was somewhat site of the tumour. The sickness had ceased and food obscure, but it seemed probable that slight protrusion had been taken and retained. The improvement was and incarceration, (probably omental in its nature,) | permanent and progressive. A simple enema was

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