Cystitis 8 With regard to the state of the kidneys, liver, and spleen, I found that The appearances of the kidneys were not mentioned (usually from 72 cases 44 26 29 11 153 "Of the above cases, in which the kidneys were either not examined, found healthy, or considered in a doubtful state, there was marked disease of the liver or spleen, or of both these organs, in 21 cases-giving a total of 93 cases, in which one or more of these important organs was found in a state of lesion.* "It was observed, that of the 134 cases in which the patients died of internal inflammations, there was also superadded marked disease of the kidneys, liver, or spleen, or of all these organs combined, in 90.† "In a rather large proportion of these cases, the disease of the liver, spleen and kidneys had evidently existed for a very considerable time previous to the patients receiving the wounds or injuries which became the apparent primary causes of death: but in very many (and this was especially observable in the renal cases) the changes were evidently of so recent a nature, as to render it probable that almost immediately after the operations or accidents, either visceral disease had been excited from a latent to an active condition, or that a state of acute congestion had suddenly been established in organs which had hitherto been suffering merely from chronic degeneration." One of Dr. C's principal objects in submitting these remarks to the profession has been, to direct attention to the frequency of renal disease in those who perish from the secondary effects of operations or injuries. We will not go into our author's reasoning upon the matter. The fact, if a fact, finds much of its own explanation. The thing is, to test the fact's reality, and that can only be done by actual observations in the dead house. For our own parts, having paid some attention to the subject, we are inclined to believe that Dr. Chevers overrates the prevalence and importance of visceral disease as a cause of these secondary affections. We are, by no means, disposed to deny the influence which such disease would exert, nor its occasional existence. But, of its frequency to the extent contended for by Dr. Chevers, we repeat that we have our doubts. For our own parts we believe that, independently of internal and constitutional causes, the nature of the local mischief exerts an important influence. If that is "From the character of the symptoms and the nature of the inflammatory lesions of which many of the patients died, I am convinced that renal disease would have been discovered in a considerable number of those cases in which the state of the kidneys was not observed, had those organs been examined after death." +"While engaged in taking notes of the above cases, from the Post-mortem Registers, I met with the following observation by Dr. Hodgkin, appended to the case of a man who sunk after lithotomy, about fourteen years ago, and in whom mottling of the kidneys was discovered after death: This condition of the kidneys was also noticed in another patient who died after the operation of lithotomy; and in others who have sunk after operations and injuries." of such a nature, that matter formed cannot get free exit, secondary inflammations and depositions are common-if it is capable of being evacuated freely, they are comparatively rare. We shall return to this subject more fully hereafter. Dr. Chevers alludes to the tendency to secondary hæmorrhage after operations in patients who labour under renal disease. He also gives some further examples of the manner in which renal disease gives rise to fatal symptoms in surgical cases. Mottled kidney is a very frequent attendant upon old strictures of the urethra. Persons thus affected are liable to be seized with shivering, vomiting, a quick pulse, and an anxious expression of countenance, but often without much localized pain; and to die with peritonitis or inflammations of other serous membranes, cystitis, and often with suppuration below the peritoneum at the base of the bladder, sometimes following the course of the ureter, and occupying the cellular tissue surrounding the kidney. "Such individuals are also apt to be suddenly attacked with inflammatory oedema of the lungs and cerebral effusions, ending in coma and death. 66 As, in cases of this description, the above symptoms not unfrequently occur as the results of the simple introduction of a bougie or sound, it becomes of importance to ascertain, if possible, the state of the urine in every case of stricture, previously to having recourse to the use of instruments for its treatment. "Adult patients suffering from stone in the bladder are often the subjects of an active form of Bright's disease. Where this is the case, the operation of lithotomy seldom fails to be rapidly followed by fatal inflammations of serous and other structures in various parts of the body; and, as I have already mentioned, there is in such cases considerable tendency to the occurrence of secondary hæmorrhage.* "Syphilitic patients are liable to be unexpectedly attacked with oedema glottidis, purulent inflammation of the larynx and diptheritis, or with rapidly-destructive forms of pleurisy, pneumonia, and peritonitis. It is generally found that the individuals who are thus destroyed have long been of intemperate habits, have suffered from the abuse of mercury, and become the subjects of mottling or granular disease of the kidneys. "Persons suffering from asthenic anthrax are apt to become affected with acute pleurisy and other internal inflammations; the effused fluids occasionally taking on a sanguinolent aspect. I have found that patients who have died in this manner have been the subjects of marked renal affections, similar to those noticed above. “Other patients, while under treatment for various kinds of surgical diseases, not unfrequently die from the effects of acute inflammatory attacks, ascribable to degeneration of the kidneys and of the other solid abdominal viscera. "From facts already dwelt upon, with regard to the effects of wounds upon patients suffering from the different stages of Bright's disease, it becomes a point of extreme importance to be borne in mind, in a medico-legal point of view, that an injury, in itself of a most trivial kind, is liable to be followed by fatal results, should the subject of it be suffering at the time from either acute congestion, mottling, or granular degeneration of the kidneys." Most of the preceding statements are, we believe, not unfamiliar to experienced surgeons, and the morbific influence of renal disease is both extensive and indisputable. Whether it operates quite so universally as Dr. Chevers supposes may probably not be so certain. Dr. Chevers urges what cannot but be considered a judicious recommendation -that every patient, on entering the surgical wards of a hospital, should have "Mr. Key, I am informed, observes, in his Lectures, that he has scarcely ever seen a fatal case of lithotomy in which there was not discovered organic disease of some of the abdominal viscera, and more especially of the kidneys." the condition of his urine tested. To establish the practical value of the advice, he urges the following sound considerations : "It is to be feared that the more confirmed forms of renal disease never undergo a complete and permanent cure; but it cannot be doubted, that during the earlier stages of the affection, while the glands are still merely in a state of great vascular turgescence (a period, by the bye, at which I believe inflammations of the serous membranes to be especially liable to occur), the disease is certainly amenable to remedies; and although, where there is reason to suppose that the kidneys have undergone a permanent structural change, every injury is attended with considerable risk to the patient, it is well proved that, even then, the disease of these organs may be rendered passive and kept down, the urine being, for a time at least, restored to its natural character. Under such circumstances, operations may not be productive of such certain danger. I have seen cases of patients suffering from stone at Guy's Hospital, where, some weeks previous to the operation, the urine had been albuminous; but this condition having yielded to remedies, lithotomy was performed, and the patients recovered without any marked bad symptoms. There can scarcely be a doubt that in these cases an operation undertaken while the kidneys were in an irritable state would have been unavoidably fatal.” He would, in all cases, then, test the urine, and examine the condition of the liver and spleen. It sometimes happens that decided renal disease is not attended with albumen in the urine. But the surgeon, if he has tested that, has done his best to arrive at the truth, and no blame can attach to him. Dr. Chevers adds:"Even where the urine has been found healthy immediately previous to the operation, I believe that there is still great necessity for testing its condition, at intervals of a few hours, during a considerable time after the patient has been removed from the operating-table to his ward; for the extremely recent appearance of the morbid changes observable in the kidneys of many of those who have sunk from internal inflammations after injuries has (as I have already stated) led me to believe that these organs often remain with merely a tendency to derangement until the disturbance consequent upon the operation causes them suddenly to take on a state of active disease." IV. OBSERVATIONS ON THE STRUCTURE, FUNCTIONS, AND DISEASES, OF THE CORONARY ARTERIES OF THE HEART. BY NORMAN CHEVERS, M.D. After a description of some peculiarities in the structure, and some observations on the functions of the coronary arteries, for which we must refer to the original, Dr. Chevers offers an account of their diseases. They are such as affect the aorta, from which they generally extend in a greater or a less degree. But the coronary arteries seem to have also some morbid changes more peculiar to themselves. They may partake in nearly all the changes resulting from acute aortitis, and have been found obstructed by recent concretions of plastic lymph. But they also present a frequent redness from staining and transudation. The orifices of the coronary arteries are peculiarly liable to cartilaginous or ossific deposits. It is not rare to find deposits of this nature partially surrounding and obstructing these openings, and occasionally encircling them with a tumid ring, which nearly, and in some cases entirely, precludes the entrance of blood. "But the mouths of both these vessels are not usually found equally narrowed; and where only one of them is affected, it is not certain that any very serious consequences are produced; as the communication by anastomosis between the right and left appears to be sufficiently free to enable the sound vessel to supply all the branches below the impediment in the diseased one; and closure of one vessel has been noticed to be followed by dilatation of the other. In the adult, their interiors are seldom entirely free from minute opacities, which are usually arranged in striæ corresponding to the course of the longitudinal fibres of the subserous laminæ between which they are situated. In advanced life, it is common to find bony deposits scattered at intervals throughout their whole extent : some of these frequently attain a very large size, appearing as narrow elongated masses, lying parallel to the axes of the vessels; rarely surrounding the canals with complete calcareous rings, as do the old deposits of the smaller arteries of the extremities, but often attaining a bulk sufficient either to close the vessels completely or to leave a very narrow and irregular passage for the blood; while the less rigid portions of the tubes become greatly dilated, and in this state occasionally suffer rupture. Except in extreme cases, this condition of the coronaries is not invariably followed by much atrophy of the muscular substance of the heart; for as the minuter ramifications of the arteries generally continue comparatively free from disease, a sufficient quantity of blood permeates the strictured vessels (providing the circulation remain tranquil) to maintain the nourishment of the organ. The coincidence of this state of the coronary arteries with the symptoms of angina has long been observed; and it appears probable that the sudden attacks of syncope, to which aged persons are frequently liable, are, in a great proportion of cases, attributable to the same cause.' Large atheromatous collections between the layers of the sub-serous tissue are not frequent But they may occasionally be pressed through ulcerated openings in the internal membrane of the vessels, and have been mistaken for pus. The coronary arteries are liable to permanent dilatation, either throughout their whole extent, or in varicose bulgings, like those of the superficial arteries of the scalp. "Their tortuosity is also greatly increased, and occasionally (the surrounding adeps becoming absorbed) they project so greatly from the surface of the heart as to appear to be attached to that organ only by a fold of pericardium. Occasionally, this dilatation is followed by rupture of one of the arteries; of which fatal result examples may be met with in almost every collection of morbid anatomy: but the occurence of that accident generally appears to be long delayed by the increased strength which the sub-serous lamina acquire during the time in which the vessel is undergoing the process of dilatation; and it is probable that, in most of the cases where this accident takes place, it is immediately dependent either upon inflammatory softening or ulceration of the inner tunics of the vessel." Dr. Chevers goes on to observe : I believe one of the most frequent causes of dilatation of coronary arteries to be, the deposition of a large quantity of fat within the interstices of the muscular tissue of the heart, which appears to produce here (as a similar process clearly does in other parts of the body) a diminution in the capacity of all the minuter capillaries distributed within the organ; and hence the main trunks, although sufficiently furnished with blood, become incapable either of transmitting their contents with freedom, or of supplying the heart with its proper nutriment; and accordingly, the large branches of these arteries suffer marked dilatation, while the cardiac muscular tissue becomes pale, softened, and atrophied: and hence arises one of the most frequent causes of rupture of the heart. It has become a subject of remark, that in the cases where death occurs from sudden rupture of one of the heart's cavities, the whole of the surface and furrows of the organ will generally be found loaded with adipose tissue; and (judging from a considerable number of specimens in the various metropolitan museums) we may also add, with the coronary arteries considerably dilated. It may not be altogether unimportant to bear the above facts in mind, with regard to the application of remedial measures in these cases. It is by no means unusual to find elderly persons of obese habits of body complaining of violent palpitation, with sensations of impending suffocation, after any sudden exertion or emotion, the application of cold to the surface of the body, or, in fact, any action which tends to determine an unusual supply of blood to the heart. In these persons, the pulse is usually weak, while percussion and auscultation shew that their hearts, although large, act feebly; the sounds being indistinct, but free from irregularity or other abnormal character. This train of symptoms is probably often dependent upon an advanced degree of that condition of the heart which I have last described; and I have little doubt that the difficulty of breathing, which nearly all extremely corpulent persons experience upon unwonted exertion, is mainly attributable to less degrees of the same changes. Acting upon this course of reasoning, I have found that the adoption of a plan of treatment calculated at once to procure absorption of a portion of the superfluous fat of these patients, and to diminish the quantity of their circulating fluids, has been followed by an acquisition of increased cardiac power, as evidenced by a stronger pulse and an entire cessation of the suffocative attacks during very long intervals." The latter recommendations deserve attention, and correspond with what we have ourselves observed. V. A CASE OF GLANDERS IN THE HUMAN SUBJECT. By H. M. HUGHES, M.D. Dr. Hughes observes that patients are not unfrequently admitted into the hospital who are supposed to have been infected or inoculated by poison, derived from the lower animals. The symptoms and the progress of the case are too various to admit of a faithful general history being given of them. The following sketch appears to us to be graphic and true. "One feature is, however, common to them all. The patients have been all more or less directly or indirectly, exposed to the liability of inoculation by putrid or diseased animal matter. One of them, a short time before his illness, was engaged in moving some barrels of salt meat, the odour of which proved that the antiseptic processes adopted had not been effective in preventing partial putrefaction; others have been occupied as tanners, knackers, butchers, horsekeepers, cab-drivers, or coachmen; or have been employed in packing or handling imported skins, or imperfectly cured animal provisions. "These patients have fever of considerable but very variable intensity, often remittent, frequently irregularly intermittent, and constantly accompanied with a moist state of the skin. They almost always complain of severe pains in the back, limbs, and joints; and often believe and represent themselves to be suffering from rheumatism. The complaint has not, however, the general aspect of that affection. The joints are not, in the first instance, swollen, red, and tender; the tongue has not the loaded, white, moist, and flannel-like appearance; and the skin, though moist, is not covered with a copious perspiration of the peculiarly sour odour common in that complaint. Pain of the head, and especially of the forehead, is often troublesome; delirium exists at night; the tongue is somewhat dry and red, at least at the tip and edges; the conjunctiva is injected; and the whole of the mucous membranes congested and irritable-symptoms which lead to the probable supposition that the disease is simple continued fever. But the absence of some of its ordinary accompaniments causes doubts to arise in the mind of the attendant: the skin is not constantly dry, pungent and hot but is at one time hot, and at another moist, greasy, and of natural temperature; there are no maculæ, and no petechiæ: and though the face is flushed, the countenance has not the heavy, stupid, half-drunken, puzzled' expression of common fever. While the physician is perhaps still undecided as to the origin and nature of the malady, a local swelling occurs upon the trunk, or more commonly about one or more of the joints; or erysipelas appears upon the forehead, cheek, or neck. The tumor slowly suppurates, or the erysipelas is followed by an ill-defined abscess of the cellular membrane. The parts heal, and the patient for a time appears to improve in health and strength; when tenderness is felt in another |