LECTURE ON CLINICAL MEDICINE. 59 Now, it was not pneumonia only that the stethoscope detected; the other physical signs implied that the bronchial mucous membrane, especially in the smaller tubes, was in a state of inflammatory congestion. The post-mortem examination confirmed this, and exhibited to you morbid complications not unusual in the pneumonia of drunkards. The immediate cause of death in these cases is asphyxia, or death beginning at the lungs. The accumulated secretion of mucus in the air-tubes as effectually obstructs the passage of oxygen to the blood as any other asphyxiating agent; and when such conditions exist, coma usually for some hours precedes death. Venous blood continues to circulate till the patient dies literally "poisoned by his own blood." Many circumstances in this case co-operated to bring on the fatal issue. In the first place, the in to the creation of an inflammatory diathesis. Again, the season of the year, and the particular condition of the atmosphere-frosty, foggy, with a very elevated barometer, most unquestionably predispose the lungs to become the seat of inflammatory action. You daily witness, among both out and in-patients, how the season of the year predisposes to pulmonary disorders. Many circumstances co-operating, a series of morbid effects followed, from which it was not reasonable to expect that the patient could survive. I have already had occasion oftentimes to remark to you, that the co-existence of acute inflammatory action, with a general adynamic condition of the system at large, is by no means rare. It is this antagonistic state of things that for the most part renders inflammatory diseases fatal; for if the powers of the system be sufficient to permit those remedies to operate, which only can arrest the progress of inflammatory action, all may do well; but if the powers of life be low, these measures often add to the prostration, while they fail to check the advance of inflammation. Nevertheless, in such cases they must not be neglected; and indeed it is not unfrequently necessary to cup, blister, and give mercurials with one hand, while the system is supported by ammoniacal stimuli with the other. physical state of the chest indicated the presence of broncho-pneumonia,-pneumonia situated probably at the root of the left lung, and an inflamed state of bronchial mucous membrane throughout its entire extent, the intensity being greatest in the smaller tubes; and I formed this opinion upon the absence of any moist gurgling of large bubbles being heard in the regions where the presence of secretion in the larger tubes is most readily detected-namely, posteriorly between the scapula, and anteriorly in the mammary region. The character of the sputa corroborated to a certain extent this diagnosis. They were copious and much was of a pure white frothy aspect, without much tenacity; but a portion was also frothy and somewhat rust-coloured, and this portion was more tenacious than the rest. Now, the pathological conditions on which these phenomena depend are these :-In that portion of the lung in which pneumonia exists, a retarda-ordinate use of intoxicating drinks at all times tends tion or stagnation of the blood in the arterial capillaries first takes place; what is the primary cause of the retardation or arrest to the even current of the capillary circulation, is not known or even likely to be. All that we can attain to is a knowledge of the conditions of any given phenomenon; the causes of those conditions are among the impenetrable mysteries of nature, and it is a useless expenditure of time speculating or guessing at it. All that we can state with certainty, is, that the earliest change observed in the capillary vessels of a part, the seat of inflammation, is a stagnation of the blood-corpuscles; their onward progress is arrested, and as an effect of, or concomitant with, this diminished motion, is the escape of a fibrinous spontaneously-coagulable fluid, which, filling the surrounding interstices of the tissue, consolidates the part, and gives firmness and solidity to what was previously elastic and extensible. In the pulmonary parenchyma this exudation not only fills the bronchial intercellular passages but the air-cells also. This accounts for the denseness and increased specific gravity of a portion of inflamed lung; and it also explains the presence of the dry crepitating sound on applying the ear to the region immediately over the seat of inflammation. This fibrinous exudation, the special product of capillary hyperæmia, contains dissolved in it much of the hæmaphein of the blood; its presence gives to the inflamed part the dark brown-red colour always observed in the first stage of pneumonia. A portion of this colouring matter, (hæmaphein,) dissolving and mixing with the bronchial mucus, tinges that fluid, a brown, red, or rust colour, and when expectorated presents us with the sputa so familiar in this disease. This constitutes the first stage of pneumonia. The next stage is the softening or breaking down into a purulent degeneration of this fibrinous deposit. In the case before us this condition had scarcely commenced, as the granular state and colour of the part testified, for as softening proceeds, all the hæmaphein of the blood is absorbed out, and a grey cheesy mass is left. When examined under the microscope only a few corpuscles that developed nuclei by the action of acetic acid were observed, the mass being composed of granular exudation corpuscles. The treatment of these cases requires great discretion. To bleed from the arm is not advisable; rapid subsidence of the vital powers often follows abstraction of blood from a vein. The most effectual and least hazardous mode of relief is by cupping between the shoulders, or over the affected side. Blistering is also desirable. Calomel, antimony, and opium, should be cautiously administered, and ammoniacal salines given at intervals the moment the pulse, by its softness, indicates their necessity. I wish to direct your atttention to the case which died in the same ward on the same day,-one also of pulmonary disease; but an emphysematous state of the lungs, with chronic bronchitis, were the characters determined by the stethoscope, and at our next lecture I wish to point out to you some of the chief distinguishing features of that case. THE LAW OF THE MORPHOLOGY OR META- HUMAN BODY. (Fourth Series of Experimental Researches.) By WILLIAM ADDISON, M.D., F.R.S., Malvern. II. ANIMAL TEXTURES. It may with great certainty be affirmed, that the blood contains the elements from which, in animal structures, the solid textures and the secretions are produced. Blood consists of a limpid fluid, holding in suspension a multitude of cells of two kinds; the one red, the other white or colourless; it may therefore with propriety be termed a cellular or corpuscular fluid. On its first discharge from the living vessels, blood is thin-that is to say, it drops like water, but it speedily becomes viscous or stringy, and then coagulates into a soft solid, which ultimately separates into two parts,— ,—a red clot, and a yellow fluid serum. But blood, before it coagulates, frequently separates into two fluid portions; the uppermost colourless, and termed plasma, lymph, or liquor sanguinis, the lower red: both these portions coagulate, so that the solid clot is in part colourless, and in part red. The colourless part of the clot, which is uppermost, and formed by the coagulation of the plasma or lymph, | is a coherent and elastic fibro-cellular texture, ordinarily termed the buffy-coat; it is usually depressed in the centre, with thin fibrous edges, and there is frequently a viscous, colourless, gelatinous mucus in the cuplike depression, that may be drawn out in strings like ordinary mucus. swell out to double their former size, and then burst open, discharging their contents, which consist of a viscous mass, mixed with molecules, and apparently identical in all its properties with natural or healthy mucus. All the mucous secretions and the saliva contain colourless cells, which cannot be distinguished by any specific character from the colourless cells of the blood, and there appears no reason to doubt that the viscous matter of these secretions is an animal product elaborated in the interior of cells identical with those which are seen floating or mingled with it. Moreover, both mucus and saliva readily form fibrils or fibres when acted on by appropriate agents. These and several other well-known phenomena observable in the animal secretions may be treated of analogically, with a view to ascertain the origin of the fibrillating elements of the plasına, or lymph of blood, the element to which its coagulation into a coherent fibrous or fibro-corpuscular texture is due. Milk, among others, is a complex animal secretion, elaborated in the interior of cells or corpuscles, and set free by the thinning away, dissolution, or rupture of the cell-wall. The yolk of an egg is an analogous example, where the cells are large, and their walls so very thin, that it is with the utmost difficulty they can be touched in the gentlest manner without rupture. To the unassisted eye, milk appears as a homogeneous, white, opaque, fluid; through the microscope its white appearance and opacity are found to be owing to myriads of minute molecules,—and it is well known to contain an oily element or butter, a fibroalbuminous element or curd, and a limpid fluid or whey, and to the sum of each of these products every milk-cell contributes its quota. The plasma, lymph, or colourless element, floating on the surface of newly-drawn blood, appears to the unassisted eye, when first seen, as a semi-transparent colourless fluid, gradually becoming viscous, and then fibrous and solid; and it is well known to contain, not The microscopic appearances in a film of blood not disposed to exhibit a colourless layer of lymph or plasma, are very different from those of a film of blood that is disposed to do so. In blood not disposed to exhibit a buffy-coat upon the clot, we see with the microscope numerous red corpuscles or cells, slightly cohering in strings and rolls, and a few colourless ones floating in a clear limpid fluid. In blood that is dis-only the solidifying fibrous, but a soluble albuminous posed to have a buffy-coat upon the clot, we see a much larger proportion of colourless cells, and multitudes of minute molecules floating with the red cells in the clear and limpid fluid; the red cells adhere more firmly to each other, and are congregated in larger and more irregular masses; and in the fluid, a network or tissue of interlaced filaments or fibrils is shortly observed to form. If a film of the colourless fluid, plasma, or lymph, be separately examined with the microscope, we find it mixed with innumerable colourless cells and isolated molecules; within the cells are a number of similar molecules, some of the cells containing much larger ones than the others; and when the coagulation commences, it is by the formation of fibres in the fluid. When water or a weak solution of potass is added to colourless bloodcells, they immediately begin to enlarge, gradually and oily element. There are then the very same reasons for concluding that the fibrinous and albuminous elements of the blood, plasma, lymph, or liquor sanguinis, are derived from colourless cells similar to those found in it, as there are for concluding that the elements of milk, saliva, or any other complex animal product, are derived from cells; and the plasma or lymph of blood, therefore, is as much entitled to the term secretion,—to be considered as the products of cellelaboration, as any of the other fluid or solid materials of the structure. An abundance of colourless cells, filled with a viscous matter and molecules, are at all times discharged or thrown off, mixed with a viscid mucus, from the mucous membranes, and their numbers are increased upon the slightest irritation or inflammation. Similar cells are at all times discharged or thrown off MORPHOLOGY OF THE TEXTURES. from all wounded and healing textures, where the process of reparation is going on-where new and conformable elements of growth are appearing, and where, therefore, the process of nutrition is normal. Similar cells are also discharged or thrown off from diseased textures, ulcers, and abscesses, from scrofulous joints, and from the cavities of the lung in consumption; in these latter instances more especially the cells have received the distinctive appellation of Pus. Pus varies in consistency: it may be nearly solid, or quite fluid,—that is to say it may be solid enough not to drop like water, and in this state it is a corpuscular texture, analogous to the incoherent corpuscular textures of the lower forms of vegetation, and the green parenchyma of a leaf. Recently excreted pus displays under the microscope an abundance of colourless cells, the interior contents of which, in various states of elaboration, present various appearances. Old pus has a different microscopical aspect, which it is well should be remembered in considering the origin of tubercles, consisting chiefly of minute molecules and granular matter, resulting from the breaking down of the cellwalls. The cells or corpuscles of healthy or recently excreted pus vary in magnitude and appearance; active molecules are frequently visible in their interior, and when water, or a weak solution of potass is added to them, they swell, burst, and discharge their contents, consisting of a viscous matter mixed with molecules. No wounded, irritated, or abraded texture, heals or ulcerates without the presence of a greater or less abundance of incoherent colourless cells; and there are no certain, specific, distinguishing marks between the colourless cells of blood, lymph and pus. When, therefore, a healing wound discharges pus, it can be regarded in no other light than as indicating a superabundance of nutritive cells, which from an actual excess in number, or some other cause, do not meet with the conditions required to make them deliver up their contents, and take part in the metamorphoses required for the reparation of the texture; but when an ulcerating wound (where there is no reparative process at all,) discharges pus, it would appear in that case, that all the cells from some inherent defect have lost the power of a conformable metamorphosis. This explanation of the appearance of colourless cells, both in healing and ulcerating textures, implies in the former case a great excess of agents in the performance of a specific office or function-viz., the healing of the wound, and this so far from being, as might hastily be imagined, contrary to, is in fact quite in accordance with, the usual plan of nature as observed in other things, and in analagous instances. The pollencells of vegetables, for example, have an important and specific function, and in what apparently excessive abundance are they produced. Of the myriads of pollen-cells discharged from the anther, how few are 61 actually expended in the fertilization of the embryo, compared with the myriads which seem to be wasted. In animals the analogous fact, too, may be produced in illustration. Again, in the repair of a fractured bone, what an apparent excess of nutritive material or callus is collected for the cure, which is subsequently removed when the fractured extremities have been united. Moreover, there are other facts in surgery pointing to the same conclusion; for healthy granulations, copiously discharging what is called healthy pus, heal rapidly by moderate and regulated pressure, which by diminishing the amount of blood flowing through the innumerable vessels of the young texture, diminishes also the amount of colourless cells, whereupon the quantity of pus diminishes, and the granulations then becoming covered with a coherent, fibrous, nonsecreting, instead of an incoherent, corpuscular, secreting texture, are said to cicatrize or heal. Colourless cells, therefore, in all cases of nutrition, appear as the primary and active agents, the results depending upon their metamorphosis. From these facts and observations, and from others fully detailed in former researches, I draw these important conclusions: First, that in all living structures,-in all plants, and in all animals, the elements of growth and secretion,-that is to say, the peculiar and characteristic solid and fluid matters of the structure, are prepared or elaborated in the interior of minute vesicular bodies, variously termed corpuscles or cells, which may either be coherent, forming a strong or solid texture, or incoherent, forming a soft or brittle, and more or less a fluid one; and that the elaborated material, when set free by the opening or rupture of the cell-wall, undergoes ulterior changes, or metamorphoses, and either constitutes a part of the solid structure, or remaining fluid forms a secretion. Secondly, that the incoherent cells of the parenchyma of the leaf are the primary elaborating cells of vegetables, and the incoherent cells of blood, the primary elaborating cells of animal structures. By the metamorphosis of the former, all the subsequent textnres and vegetable colours and secretions are produced; and by the metamorphosis of the latter, all the animal textures and secretions. The incoherent parenchymatous cells of the leaf are in all their stages stationary; and the air necessary to their respiratory functions passes to and fro around them by the motive power of heat. The incoherent protoplasma cells of blood flow in streams throughout the body, traversing in their course the walls of the coherent cellular and aeriferous texture of the lung, into and out of which the air passes by the motive power of muscles. Thirdly, that the relations subsisting between animal textures or secretions, and the blood, are analogous to those subsisting between vegetable textures or secretions, and the leafy parenchyma; and therefore that the law of the morphology of animal, must be analogous to that of vegetable, structure. In the latter instance, the doctrines based upon the law do not profess to give any reason why the parenchyma of one leaf differs from that of another,why oil of peppermint is formed or secreted in one set of green cells, and prussic acid, opium, or bergamotte, in another; nor does it enter upon the question of the differences prevailing among the green granular cells of different parts of the same plants on the contrary, the doctrines trace the form and mechanical properties, rather than the physiological function of the textures; so that the main features of morphology are only secondarily affected by differences and variations in secreted products. So likewise it appears to be in animal textures, that the morphology, in respect of form, is a branch of physiology sufficiently distinct from the morphology of secretion; and to admit, as is the case in plants, of a separate consideration. "If we consider," says MOHL-and he is speaking of the cells of plants-"the place at which, in the interior of a cell, new cells are on the point of being formed, and at which the nuclei have already made their appearnace, we find that the future mother-cell contains a viscous colourless mass, mixed with minute granules; and since this viscous mass everywhere precedes the first solid formations, I trust it will be considered justifiable, if I propose to designate it by the word protoplasma, a term which recalls to mind its physiological function.* Now it is evident, in the universally-existing process of cell elaboration, and whether the result be new cells, or permanent, cellular, or fibrous structure, or fluid secretion, that two distinct stages are recognised. In the first, the elaborating matter,—the protoplasma or primary element, (adopting the term proposed by MOHL,) is in progress of preparation within the cell, shut out from all extraneous or exterior agents, except those specially admitted through the cell-wall to assist in the elaboration. In the second, the elaborated matter having been set free by the opening or rupture of the cell-wall, undergoes its ulterior metamorphosis, subject to the action of new agents, which may influence conformably or unconformably, the completion of its permanent phase. The liquor sanguinis or lymph which rises to the surface of newly-drawn blood is, if we adopt MOHL's term, the protoplasma of animal structures, and the buffy coat, is a protuphasma, a fibro-corpuscular See MoHL's paper "On the Circulation of the Sap in Plants," in the "Annals and Magazine of Natural History," July, 1846. (Translated from the Botanische Zeitung for Jan. and Feb., 1846.) This author objects to the term mucilage, employed by Schleiden to designate this substance, as the term "vegetable mucilage," in the sense in which it is ordinarily used in chemical works, conveys a totally different meaning. The protoplasma of MOHL is termed" plastic element" in my "Researches," &c. * texture, which, were it still within the vital influence of the whole structure, would, according to its analogies, become a secreting texture; and, moreover, the mucous or jelly-like matter often found in the depressed centre of the buffy coat is, in reality, the last change or secretion of this altering cell-texture. "The glairy fluid. termed mucus, being nothing more than an altered state of the fibrillating liquor sanguinis, the change from the one to the other being coeval with the changes within the cells. Hence, if we take the red portion of the buffed clot, and the red cells to represent blood, then the colourless layer of liquor-sanguinis (the protoplasma,) will represent the first remove from blood, and mucus or pus will be next; and it would appear, generally, that the nearer the cell is to, or the fewer the stages of its removal (by morphological changes,) from, the circulating current, the more nearly it resembles the colourless blood-corpuscle, and the more decidedly and visibly its fluid contents, when they escape, fibrillate; whereas, the further the cell is, or the greater the number of stages of its removal (by morphological changes,) from the circulating cells, the larger it is, and the less perfectly do its fluid contents fibrillate."+ "The blood can hardly be said to be organized, yet from the physical characters of coagulated fibrin, it is evident that while circulating in the body it holds a peculiarly endowed animal principle, (fibrin,) requiring only a moments rest to constitute solid, organized (I do not say vascular,) tissue. The texture, formation, cohesion, toughness, and elasticity, are all proofs of its organized nature; and it at once, without further aid or assistance, assumes all these properties, even after its removal from the body in venesection, or after death in its own vessels. There seems then, to be but one step between the microscopic capillaries and the fibrin of the blood; the former are minute fibrinous channels, the latter may (not inappropriately,) be termed organized tissue, circulating with the blood." (Medical Gazette, March 26th, 1841.) These are sentiments expressed upwards of five years ago, and subsequent researches have confirmed the idea I then entertained. The term 'fluid texture,' may be objected to, nor can I contend for the congruity; but this does not alter the fact that the blood is a cellular fluid, and a clot of blood a fibro-cellular texture. The incoherency or brittleness of the lower portion of the clot is owing to the predominence of cells; the coherency and toughness of the upper part to the predominence of fibres. • Prot-aphorismus-the mucus having the same relation to the solid fibro-cellular texture that the protoplasma has to the incoherent cells of blood. +"Second Series of Experimental Researches," p. 16, &c.-Churchill; London. (To be continued.) PHLEBITIS OF THE VENA CAVA INFERIOR. A CASE OF FATAL PHLEBITIS OF THE IN- By J. BLACK, M.D., Senior Physician to the Manchester Union Hospital. (Read at the Manchester Medical Society, Jan 6, 1846.) Martha Wright, aged 26, unmarried, a domestic servant, but who, from the history of her habits, had led somewhat of a wandering and irregular life, was admitted on the 14th of August, 1846, into the Union Hospital, labouring under sub-acute rheumatism of the fibrous character, attended with simple derangement of the stomach and bowels. She was forthwith confined to bed, put upon low diet, and the Vinum Colchici, with Nitre in Julep of Acetate of Ammonia was prescribed for her. On the 17th, she had, in addition to the above, which was then given in intermittent doses only, a pill every night, of calomel and antimonial powder, two grains of each, along with half a grain of opium. On the 20th following, from her complaining of a pain in the right hypochondrium, she had a blister applied, and her pill was given in the morning as well as at night. 63 thirst, little urine, the bowels were nearly regular ; her tongue clean, but dryish, and her pulse small, frequent, and irregular; she, however, had no cough nor dyspnoea, nor could any bruit be heard in the region of the heart. I may also mention, that though her lower limbs were disposed to cedema since she came into the hospital, yet, at this period, the 17th, they had become much infiltrated up to the hips, though they retained their natural warmth. Considering the general debility of her system, it was not thought expedient to apply even leeches, but her saline diuretics were increased, along with half-ounce doses of the bitartrate of potass every second morn ing, and the constant application of emollient cataplasms and oily liniments. By these means, the indications that were in view, of promoting a safe hydrocatharsis, and an increased flow of urine, were fulfilled, but there was no amelioration to the increasing tumefaction and tension of the abdomen, and to the swelling of the thighs and legs. In addition to the enlargement, which was early evidently owing to a fluid, from the very characteristic fluctuation elicited, there was by the 24th, observed all over the anterior aspect of the thorax and abdomen, well-marked enUnder this treatment she was entirely relieved from largements of the epigastric and external mammary her rheumatism; and on the 24th, the colchicum mix-veins, both of which sets of vessels were perceived ture was omitted, as well as her pill in the morning. to inosculate freely and directly with each other. She was then considered so far convalescent as to be permitted to leave her bed during the day. On the 27th, her pill at night was also omitted, from her gums becoming a little tainted by the mercury, and she had simply at bed-time, a small dose of Dover's powder, along with generous diet daily. On the 4th of September, she was seized with the diarrhoea that, more or less, prevailed at that season as an epidemic, for which she took the cretaceous mixture, and trom the complaint being rather persistent, she was again confined to bed, and on the 10th she had a pill every six hours, composed of the diacetate of lead and opium, which soon relieved the urgency of her symptoms. Within the subsequent four days, her diarrhoea had entirely ceased, but along with its cessation, her abdomen began to be very tense and painful, and scarcely allowed the least pressure of the hand. In spite of large emollient poultices, and cooling saline medicines to act upon the kidneys, the swelling and tension continued to increase, with much restlessness and pain. This appearance in a few days became still more evident and interesting; the main branches became larger than swan-quills; and in passing the finger across the tract of many of them, a perceptible depression was felt, equal to the depth of half the cylinder of the respective veins, while they became full and distended below, and relaxed above the point of pressure. Some internal obstruction to the return of the venous blood to the heart from the lower parts of the body was now evident, but on what it depended was a problem not easy to resolve. No tumour had been detected nor even suspected in the abdomen during her period of diarrhoea, and nothing could be elicited from the chest or heart that could account for this sudden enlarged and vicarious venous circulation. The only conclusion that was come to at the time was, that the rapid effusion into the abdomen, along with the tensive resistance of the parietes, had acted as a counter pressure on the abdominal cava, and so impeded its transmission of the blood from the inferior parts of the body. With this view our medicines were continued, along with the Linimentum Hydrargyri et Linimentum Camphora, and calomel with a little opium was readministered on the 27th. The disease, however, suffered no remission; for though the bowels acted freely when required, and the urine was kept to a normal amount of excretion, with a diminution of the tension and pain in the abdomen, yet the amount of effusion seemed to increase with more encroachment on the capacity of the thorax; the anastomosing veins continued enlarging, and the vital forces of the body and powers of the mind The case having by the 17th put on a very important and serious character, it was more strictly investigated, and the conclusion then arrived at was, that it was one of rapid and diffuse peritonitis, of an adynamic nature, with effusion into the cavity of the abdomen. This result was supposed to be occasioned by the quick stoppage of the diarrhoea, and the repellent effect of cold, while attempting to go about at the time she was constitutionally influenced by mercury; she was besides of a delicate frame of body, and I had some reasons to think that she had been previously evidently began to give way under the incumbent intemperate. Her skin was at this stage warm through-affliction. out; her abdomen rather hot to the hand; there was On the 8th of October, regular medicines were omitted, |