페이지 이미지



It must be borne in mind that the inflammatory | You must bear in mind, however, that the absence of process in some forms of phlebitis does not pass beyond these general symptoms is not to be taken as an index, the deposit of the plastic lymph, and that no farther that little is required to be done, or that the case is morbid change taking place, the blood escapes that trivial, and needs but slight attention. So long as the fearful purulent contamination, which, if once estab- vein is the seat of inflammatory action, so long as a lished, rarely terminates otherwise than fatally. fibrinous deposit clogs up the canal, suppuration of the

The case we have just seen presents us with an plastic mass may be dreaded, not remotely, not contiaexample of an exemption from these terrible second gently, not merely accidentally, but as a change strictly ary consequences; you inast, nevertheless, not forget in obedience to the organic laws governing these patbothat however trivial and light the symptoms may have logical products. It must be our object, therefore, in appeared to you, a case of inflammation of the veins the treatment of such cases, to avert if possible this from whatever cause, must be considered serious, as much dreaded mode of termioation. This can only be the tendency to purulent degeneration of the plastic effected by the judicious and persevering application of mass is greater than either to its solution, removal, or those remedies that have been already indicated. The semi-organization. When purulent transformation of period of convalescence must be treated with caution ; the deposited lymph does not take place, it is often there is a special tendency to relapse in these cases; remarkable with what rapidity the plug disappears, and the local inflamination then re-appears with an intensity the function of the vein as a permeable tube is restored. that no remedies can check, and which now passes In the case under consideration, in the course of a rapidly and uncontrollably into purulent transformation few days, the veio had become soft, and evidently and inevitable death. permeable. Hasse states that this change is effected The rheumatic diathesis does not often express probably by the liquefaction and solution of the plastic itself by phlebitis ; yet it is not difficult to understand, mass in the circulating fluid, and a channel by this that in certain morbid conditions in which :he fibrinous means is again opened to the sanguineous current, and elements of the blood are in excess, and a general there are many reasons for supposing that the exuded inflammatory predisposition exists, cold locally and lymph is not removed by absorption by the pasa continuously applied to the lower extremities, in a vasorum, but is absolutely dissolved in the blood, and manner favourable to local derangement, may precarried away into the general circulation. The removal dispose to inflammation of the veins of those parts. of the fibrinous deposit in this case, and the subsidence There must, however, be a special idiosyncrasy to of all farther symptoms of inflammation, were consenta determine the inflammatory action to the venous neous with the faint indications of ptyalism produced tissues, rather than to the fibrous tissues, muscles, by the small and alterative doses of mercury. From ligaments, tendons, or synovial membranes, as is most this moment the cord-like hardness disappeared, the frequently observed in rheumatic inflammation. In veins in the greater portion of their course had fine, this case teaches us, that under special circumbecome soft and elastic, while the dusky line which stances, exposure to cold and damp, acting on the marked the course of the inflamed vessel had entirely rheuinatic diathesis, is to be considered among the disappeared.

| predisposing causes of idiopathic phlebitis; and that Phlebitis in all its forms presents us at the outset though 'rarely developing this disease, yet under with all the characteristics of a sthenic inflammation, favourable circumstances, and in peculiaridiosyncracies, and the treatment must be based on those principles these causes are competent to call it forth in its mildest, which experience teaches us are most successful in as well as in its most formidable, aspects. arresting the results of inflammatory action. A general antipblogistic regimen must be strictly enforced. Mer. curials, with opium, or Dover's powder, are the best the LAW OF THE MORPHOLOGY OR META. alteratives. The lower extremities of this patient were MORPHOSIS OF THE TEXTURES OF THE for pearly four days enveloped in hot moist flannels,

HUMAN BODY. constantly renewed. The best results have followed

(Fourth Series of Experimental Researches.) this treatment; the patient is convalescent, and the hardened plastic deposit in the saphena veins has nearly

By WILLIAM Addison, M.D., F.R.S., Malvern. disappeared. The amount of constitutional disturbance

· XI. STRUCTURAL CHANGES PRODUCED BY was bat slight; beyond the appearance that the counte

SCROFULOUS DISEASE. . nance indicated of deranged bealth, there was no

(Continued from page 171.) symptom of any moment declaring that the general A man, aged 37 years, died of bæmoptysis and functions of the chylo-poietic viscera were much l phthisis. The body was examined forty-eight hours deranged ; the appetite was not deficient; the bowels

afterwards. not irregular; but the urine was loaded with urates,

On opening the chest, the right lung was immediately uric acid crystals were also apparent, and there was

seen to be totally different from anything resembling a 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 till the terrible condition of purulent degeneration of degree collapse upon the opening of the chest, but che 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

points to the costal wall. On attempting to separate On making sections into the right lung, the normal the adhesions, the texture composing the lung was texture of the organ could no where be found, the found extremely brittle, crumbling down under the whole of it having been transformed into the brittle fingers like dry gingerbread, and every now and then ash-grey substance before-mentioned. This new and 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 wbite or grey, both portions containing numerous in the first place was found altered in vascularity and cavities ; those situated in the red parts differing, appearance; it was very much thickened by indumerable however, in many particulars, from those situated in the layers of a fibrous texture, infiltrated with transparent white or grey. The free surface of the walls of the gelatinous (mucous) matter. The fibres were seen by a former,—the red, for instance, was smooth and unilens to be curled or waved, and elastic; in the direction form, covered with a soft, pultaceous, white material, of their length several red vessels traversed between beneath which were large straggling red vessels, visible and among them, and their minute branches extended to the naked eye, ramifying in all directions. The free into, and subdivided in, the gelatinous material. The surface of the walls of the cavities in the white subarrangement and size of the vessels in one layer of this stance was very rough, resembling a miniature rockfibro-gelatinous texture, bore no resemblance to those work, irregular eminences and projections, and someof another layer, and in all it differed essentially from times bands, thrusting out on all sides, partially dividing the mode of distribution of the vessels of the healthy the cavity into numerous compartments. These pleura. In one of these fibro-gelatinous layers I irregular walls were here and there reddened in patches counted with the lens fifteen vessels, pretty nearly by blood-vessels, but altogether the vascularity was equal in size, running side by side a straight or parallel much less than upon the smooth walls of the cavities course of an inch or more, without giving off any in the red texture. The substance of the lung, where. branches, or receding from, or approaching nearer to, soever small portions were examined with the microeach other; their internal diameters varied from scope, -whether in the whiter, or as Dr. Williams

4th to Loth of an inch, and they were distant from describes it, parsnip-coloured, portion, or in the red, each other, about the 'ob. The intervals between was found, composed of colourless cells, granular matter, the vessels, including the walls of two contiguous ves- and molecules. The white pultaceous matter living sels, consisted of glistening waved fibres, imbedded in the surface of the cavities in the red portions of the gelatinous matter. Under the microscope this gela structure, was a corpuscular or incoherent cellular tinous or mucus-like matter, the relations of which texture, (nearly solid pus,) and the coats of all the have been traced in former researches, had the appear- minute blood-vessels which were examined with high ance of a fibrous texture, thickly studded with colourless magnifying power, were found chiefly or entirely comcells; and the red vessels traversing it had no other coats posed of similar objects or cells. or walls than what were formed by the material itself.

[graphic][subsumed][subsumed][subsumed][subsumed][ocr errors][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][ocr errors][subsumed]

Fig. VI,-A blood vessel, from abnormal fibro-gelatingus texture, on the surface of scrofalous lang.-Case 2,




[ocr errors]

A girl, aged fifteen years, was seen but once, lying adhered to the walls of the chest. The adhesions were in bed upon the left side, with the knees drawn nearly | very brittle, and when broken down, which they easily up to the chin ; the eyes were suffused with tears, and were, the surface of the pleura, both on the lung and the conjunctiva red; the pulse was feeble and quick, on the chest, was found rough from: granulations the tongue red and dry, and she complained of head- similar to those within the pericardium. ache ; there was a slight squint in the left eye, and Upon examination with the microscope, incoherent upon trial the left hand and arm were found weaker colourless cells, and but slightly coherent corpuscular than the right. These last two symptoms it was sup- or cellular textures, were found to be the chief and posed were new or recent, for upon inquiry they had characteristic elements of the granulations, of the soft not been noticed before. Upon farther investigation matter of the adhesions, and of the walls of the minute it was found that the illness commenced two months branches of the new vessels.* before with influenza, cougb, 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 vesselschild, who died of hydrocephalus. Case not related.

Fig. VII.-A capillary vessel from the pia mater' of a 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 hydatid Fig, VIII - Large vessel of pia mater, (normal.) like 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 Fig. IX.-A blood-vessel of the same size as Fig. 8, the texture, and the hydatid-like bodies were groups from an opaque spot of pia mater. Case 3. of similar cells. The softened portions of the brain

Other cases, of which I have notes and illustrations, were composed of multitudes of incoherent cells,

might have been added to these, but as they all bear resembling pus-cells, which had replaced the nerve

upon the same point, -the replacement of the normal tubes, and destroyed the normal firmness and con

elements of the structure by incoherent cellular forms, sistency of the structure.

i'it : On opening the chest numerous large red vessels aning the chest numerons large red vessels / In making these microscopic examinations, I remove

small portions of the textures with as much blood as can be were seen branching over the pericardium, and the

preserved in the vessels, immersing them in a weak solution interior of the pericardium was found rough throughout of salt and water. In this way they may be kept full of to the touch from multitudes of small granulations. The

blood for some hours, and wben the small vessels are

examined, the red cells may be seen flowing along them, right long contained many tubercles, and the left lung I rendering the parts more distinct,


and gelatinous or tuberculous matter, and are all, But the case is different in respect of the cavities; they tberefore, similar to one another I have deemed the extend into the prominences on the surface of these, abree cases related sufficient to establish the facts upon and ramify abundantly in, and impress colour upon, which my conclusions are grounded ; and it appears to the bands so frequently stretched from one point to me that no one is entitled to disclaim against the con- another of their parietes. If a portion of the wall of a clusions, on the presumption that my microscope is cavity be placed under water, after all mucous and puru. a bad one, or that my eyes see more than other peoples, lent matter has been washed from its surface, this surface and at the same time decline to inform me of the is seen studded over with tufts of new vessels, which, truth. It seems hopeless to attempt to make any pro- taken together, represent a sort of villous structure, as gress in the knowledge of disease, if, contrary to the observed with a coinnon lens. “Hence," observes rules by which experimental researches are estimated the author, M. GUILLOT, “it is not only the highly in other sciences, it be allowable in physiology and vascular network surrounding the cavities with its new pathology for any nameless we to dogmatize, without circulation, that constitutes a striking feature in the offering any evidence to shew that work has been done, anatomy of these excavations, but farther, the terminal and different facts arrived at upon the same subject. tufts or villi which bring arterial blood derived from However copious and extensire a man's scientific the aortic circulation into contact with the air, having knowledge may be, and however much or long he may replaced the normal capillaries which before brought hare used the microscope on other topics of investiga- | venous blood in contact with the air."'* tion, he derives from these sources no ground of My microscopical investigations not only corroborate authority to pronounce judgment, either for or against these prior researches, which appear to me to have mpy facts, inferences, or conclusions.

| been strangely neglected, but I think they go farther, Now, the first conclusion which it appears to me mayat and prove that this great vascular transformation is once be drawn from these pathological researches is,- only one of the accompaniments of a great metamore that the deposit of tubercles, or of tuberculous matter, phosis of the pulmonary textures, in which a coherent, either in the parenchyma of the lung, or in the texture elastic and homogeneous cellular texture, with nonof any other organ, does not explain the pathology of secreting capillaries, is supplanted by a brittle, soft, consumption, or of scrofulous disease in general. This corpuscular texture, with new vessels copiously excret. corresponds with the fact, now well known, that ing or discharging corpuscular or cellular forms. tubercles may exist to a considerable extent in the But it has been proved from a minute examination of lungs, and yet no consumption follows. Tubercles and the condition of the embryo textures, and of the nature phthisis have not the relation of antecedent and conse-, and composition of blood, that the law or order of the quent. These investigations, on the other hand, dis-, metamorphosis in the normal growth of the structure close a vast scene of activity,-new textures, new blood is from incoherent corpuscles containing a secreted vessels, new elements, and a busy scene of excretion, material, to soft and brittle corpuscular secreting amidst which the normal texture disappears, and the textures, and from these to the coherent, non-secreting, natural functions of the organ therefore necessarily cellular and fibrous; and therefore, if a coherent, cease.

cellular, and fibrous non-secreting texture becomes The researches of SHROEDER VAN der Kolk, and changed into a brittle corpuscular secreting one, the more especially those of M. NATALIS Guillot, have metamorphosis is retro-grade.t Whether the incoheshown that a great transformation in the vascular rent corpuscles or cells, which are the distinctive system of the lungs is one of the remarkable pheno elements of the new textures and of the coats or walls mena attending the evolution of phthisis. The injec of the new vessels, and which so abundantly appear in tions, dissections, and microscopical examinations of the matter excreted or discharged from them, be the the latter especially, have shewu that as the capillaries identical colourless cells which previously circulated of the walls of the air-cells, and the branches of the in the blood, or whether they spring by a species of pulmonary artery supplying them, are obliterated, they secondary growth from germs in the morbid texture, are replaced by an adventitious vascular system, sup- is a question that need not now be entered on. It plied not with dark and venous blood, but with arterial, is sufficient for the conclusion just stated that incoderived from the bronchial arteries, and from the herent colourless corpuscles, whether springing from Fessels of the mucous texture of the air-tubes. In the texture or the blood, with very thin and tender proportion as the tubercles enlarge and soften, this new vascular system spreads more and more, replacing the • See Observationes Anatomico Pathologici, gc., of branches of the pulmonary artery, until their existence

SHROEDER VAN DER KOLK, L'Experience, tom, i., p. 545;

and Researches on Phthisis, by Louis, Syd. Soc. Ed. ceases to be matter of demonstration. These new

+ The terms secreting and non-secreting are used here in formed vessels, which at a certain period of the disease compliance with the common usage, but in all cases it is become incalculably numerous, stop short around the

eorpuscles or cells that secrete the blood vessels, and tubercles, without penetrating into their substance. throw off or discharge,

textures excrete; the former prepare or elaborate, the latte



'walls, filled with an elaborated or secreted matter and / had existed for some time previous to the present -molecules, and analogous to those seen in the embryo period. She was under the care of Messrs. Shelley textures, have taken the place of the transparent, and Stilwell, of Epsom, to whom I am indebted for coherent, strong and elastic, cellular and fibrous most of the following particulars; and when I sare textures. All that need be affirmed is, that corpuscles her with those gentlemen, unequivocal symptoms of or cells, apparently identical with those which form the strangulation of the hernia) tumour had existed at elements of, and are excreted by, the morbid texture, least three days. The swelling bad enlarged concirculate abundantly in the blood, and may be seen siderably, there was much abdominal pain and tenders adhering to, and altering the character of, nutrient Dess, obstinate constipation, constant nausea, and vessels; and these facts, established by observation and copious voniting of decidedly stercoraceous character. experiment, are sufficient to explain the origin of the The symptoms bad suddenly supervened, and gradually elements which effect the structural changes. . increased in intensity. In the first instance, the

But before this conclusion can be admitted as stomach had retained large doses of cathartic medicine, the basis of the pathology of scrofulous diseases, it castor oil, and calomel, though without any aperient is necessary that its foundation on natural laws be effect, but now ererything was rejected as soon as substantiated by further investigation.

swallowed. All the usual medical means available bad (To be continued.)

been unsuccessfully resorted to, and the taxis bad | been carefully and repeatedly applied. The tumour

had now become exceedingly tender, the countenance OBSERVATIONS ON HERNIA, AND ITS

assumed an anxious expression, and the pulse was TREATMENT BY OPIUM.

accelerated. There could be no doubt that the By BUTLER Lane, M.D., M.R.C.S.E., &c. &c. operation was desirable, and that without delay, but Among the most serious emergencies of surgical to persuade the woman to submit to it was impracpractice may be reckoned cases of strangulated bernia. ticable. I again employed the taxis unavailingly. This is especially the case in country practice, where & cathartic enema was then ordered, and any farther there may be lack of counsel to impart confidence in procedure was remitted till the following morning, action, and where life may depend on the judgment when we hoped by other means to induce the woman and energy of a single professional individual. Even to undergo the necessary operation. in the metropolis, where abundant experience and When I again met Mr. Shelley and Mr. Stilwell, operative skill are available, it must be acknowleged, we found all the symptoms bad increased in urgency, that such cases often occasion considerable embarrass- and the vital prostration was become more obrious. ment. It has always been an object of surgical | Our patient, however, was no less refractory and science to supersede the necessity of operation, in cases obstinate than heretofore. Her danger was imminent, of strangulated hernia; other objectionable circum- and in fact, death seemed almost inevitable. The stances besides the danger, place the operation in state of depression rendered a tobacco enema objection. question among the foremost of the opprobria medicine. able; it was, however, agreed to try it, but though I am therefore induced to direct the attention of the its sedative influence was fearfully powerful, yet it profession to a method of treatment, which has been did not seem to afford any advantage, no fæcal attended with such marked success in two consecutive evacuation being obtained, and the stercoraceous instances, as to convince me that it deserves a fair vomiting and other symptoms continuing as before. and extensive trial in the arena of hospital practice | As a last resource, I then suggested the adıninistration

The plan I am about to advocate, consists in / of opium, in doses of one grain every hour, which was narcotisiug the patient by the free and continuous agreed to, though with but little anticipation of administration of opinm. Where or with whom this effectual relief. method of treatment originated, I know not, but Il I saw the woman next day with Mr. Stilwell, and shall be happy to surrender the merit of suggestion was agreeably surprised at the change which had taken to any just claimant. When I adopted the practice place. Twelve doses of opium bad been administered in the first instance, I bad a vague idea of having seen and she was fairly under its influence, having the the use of opium in hernia identioned in some periodical, appearance of a helpless state of intoxication. She and my memory did not serve me farther; but from had slept much, and when roused, her answers and considerations, hereafter to be mentioned, it seemed conversation were very incoherent. The pulse had to me feasible in affording some prospect of relief. 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 bernia, 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

« 이전계속 »