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The large intestine, except from the sigmoid flexure downwards, was contracted. The cœcum was narrow, and scarcely projected beyond the end of the ileum. The appendix vermiformis was short, serpentine, and adherent. The mucous membrane of the colon, lined with yellow, healthy-looking feculent matter, was partially inflamed, and presented numerous small ulcers, of a round, or oval form. Some of these ulcers were seated on an inflamed base; but others appeared as if punched out of the sound membrane by a sharp cutting instrument. A few similar ulcers were found on the inner surface of the extremity of the ileum, and on the edges of the ileo-colic valve, but did not seem to extend further upwards in the small intestines. The veins of the mesentery were, in general, much distended with blood. Its glands were enlarged, oblong, and of a dirty-white colour. Near the cœcum, a few smaller glands were harder, and more globular.
The liver was of fair size. Its peritoneal coat was rather dark coloured; owing, perhaps, to the incipient extrication of sulphuretted hydrogen gas. Internally, it was soft, and slightly mottled throughout, with angular, or polygonal, white lines; but, on section, it yielded no exudation, either of blood, bile, or serum; although the venous trunks traversing its substance, as well as the inferior cava, were large, and thin. The gall-bladder contained a little orange-coloured bile, diluted with mucus, but without concretions. The spleen was rather small, and conglomerate, its internal condition varying in different parts; for, on making sections into it, one portion was found of its usual dark hue, while an adjacent portion was of a light red colour, and soft texture, with a paler, peritoneal coat. The pancreas was small, slender, and soft, with distinct, and full-sized lobules. The kidneys, containing little urine, and destitute of fat, were fleshy, firm, and nearly in a natural state; but the right kidney, corresponding to the pulmonary vomica, was diminutive, and its ureter very slender. The urinary bladder was empty, and collapsed.
REMARKS. The interest of this case of pulmonary consumption chiefly consists in the contrast which it presents between the progress of the same disease in the opposite sides of the chest; and in the gradual, and silent manner, in which almost the whole of the right lung had been destroyed, and removed; while the left lung, although greatly disorganised, was nearly in a solid state. whole probably depended on the absence, or, at least, on the low degree of inflammatory action; a circumstance strongly marked in the remaining lung, wherein there was
neither adhesion, effusion, nor hepatization, but, on the contrary, small portions of healthy pulmonary substance were, in many instances, intermingled, and in close contact with tubercular masses; showing that inflammation has no necessary connexion with phthisis, either as cause, or as effect. The same fact was, in some measure, displayed in the mucous membrane of the colon, which contained a number of small, circular, phagedænic ulcers, entirely free from surrounding redness, or turgescence; and which were, more probably, the result of nervous, than of vascular action. The irritation of various portions of the mucous lining of the ileum, and colon, so common in the latter stage of phthisis, is, evidently, a sympathetic affection, remotely excited by the diseased lung; and the medium of intercourse in this, and, in other cases, seems to be furnished by the minute, but important, and universally diffused nerves of the ganglionic system, which preside over the nutritive functions; and, according to their varied condition, are capable of increasing, lowering, or modifying vital action, in the parts which they supply, and, thereby, of producing all the diversities of vascular action, as well as of organic composition, or dissolution.
Another interesting circumstance presented by this case is the clearness of its diagnosis, resulting, chiefly, from the absence of respiratory murmur throughout the whole right side of the chest, in conjunction with its contracted, and excavated form, and with deficiency of resonance on percussion, until the immense vomica which it contained had been partially emptied; when, together with returning resonance, the characteristic sign of metallic tinkling was distinctly added. The value of the acoustic signs, on such occasions, may be estimated by comparing the prompt, and certain knowledge of internal conditions, attainable by their aid, with the vague conjecture, or total ignorance, which are the unavoidable consequence of neglecting them.
This case, when compared with the preceding one, displays, also, the striking contrast which exists between the two principal forms of pectoral abscess, namely empyema, and pulmonary vomica, according to their situation, within, or without the pleural sac, in their influence on the dimensions of the thoracic cavity; which the latter tends to diminish, and the former, at least in the first instance, to enlarge. The enlargement is manifestly occasioned by the pressure of a confined, and accumulating liquid. The diminution seems to depend on a slow, but powerful contractile process, which, in the pleura, as in other serous membranes, whether original, or adventitious, is induced by inflammation; and which, as my friend, Dr.
Hodgkin, and other pathologists have shown, usually produces a remarkable effect on the shape, and size, of the parts to which they are attached.
In the last place, this case, in common with many others, illustrates the specific, and, to a certain extent, the hopeless aspect of phthisis, as resulting from a peculiar aberration of the nutritive functions, originating, probably, in the ganglionic system, and, in a great measure, beyond the reach both of investigation, and of relief. In its earliest observable stage, the disease exhibits a number of membranous vesicles, of a distinct, and malignant character, somewhat like obstructed, and dilated follicles; absorbing nutriment from the surrounding parts by their external surface, and secreting within their cavities a whitish, albuminous pulp, at first semitransparent, but afterwards opaque, and, in appearance, resembling soft cheese. Near the surface, and, more especially, at the summit of the lungs, a few tubercles of large size are sometimes found, and may be compared to the indolent deposits which, in the common cellular membrane, give rise to strumous abscesses; but, in the interior of the organ, they are usually small, and numerous. When they have attained a certain period of development, either from the distention of their accumulating contents, or from some other cause, they seem to lose their vitality, become softened, and are commonly discharged into the bronchial tubes, leaving so many empty, and, in general, suppurating cavities in their room.
This process includes all that is essential to phthisis; which, as in the case now under consideration, sometimes pursues a simple and tranquil course, attended with little pain, or disturbance, until, by compression, and interstitial absorption, the greater part of the lungs has been silently removed; so that, when the tubercular growth which has usurped its place falls, at length, into dissolution, the sooner, perhaps, in consequence of being thus by its own agency deprived of nutriment, a vomica of the largest size is suddenly created. If, on the other hand, the tubercular deposit is more limited in its extent, and more equally intermixed with the pulmonary substance by which it is sustained, it may for a considerable time retain its firmness, and the vomicæ in which it ultimately terminates are either small, and detached; or, if larger, attain their bulk, by successive confluence, producing, often, an intricate and extensive labyrinth of pulmo
The more active and distressing varieties of phthisis may, perhaps, in part depend on original differences of organization, and of susceptibility; but, more immediately, on the
addition of inflammation, in various forms, and degrees, either of the pleura, of the bronchial membrane, or of the pulmonary substance, to the original tubercular deposit. By such inflammation, and its results, the local symptoms of pain, dyspnoea, cough, and expectoration are aggravated, and the organic nerves derived from the eighth pair, and from the ganglionic system, are violently irritated, giving rise to sympathetic disorder in various points, together with hectic fever, cerebral disturbance, and universal restlessness, and distress. In the former case, the greater part of the lungs is gradually, and insidiously undermined, and death is chiefly induced by the abolition of their indispensable function. In the latter, while a large portion of the organ remains apparently sound, the more penetrating inflammation, and ulceration of a small fraction of their substance is sufficient to occasion intense suffering, and to accelerate death, through the medium of fever, and of irritation.
Hence, the supreme importance of early diagnosis, to recognize the morbid disposition, and of early treatment, to anticipate, if possible, the tubercular formation. The hopeless aspect of the complaint, when far advanced, must be evident, from a consideration of its nature, and tendency. Individual cases may, undoubtedly, differ greatly, in severity, and in extent; much may be done by preventive measures; and, more especially, by the cautious use of iodine, the universal antidote of scrofula; pulmonary ulcers, when of limited character, may admit of being cicatrized, or of being lined with false membrane; but, when the disease has once attained a certain growth, no remedy with which we are at present acquainted, or which we are likely to discover, can repair the injury committed, remove with safety the adventitious deposit, or restore the pulmonary substance already destroyed.
Cases extracted from the Obstetric Note-book of the Welbeckstreet Dispensary, by permission of HENRY DAVIES, M.D., Physician to the British Lying-in Hospital, &c.
CASE I. A copious Discharge of a Watery Fluid during
FEBRUARY, 1825. Anne Scott, æt. twenty-seven, applied at the Dispensary, stating that she feared she should be delivered even before she could reach home, as she had been discharging a clear, watery fluid, for the last three or four days, and could feel the child exactly as if it were coming into the world.
She has had two children, and has miscarried once, but
has never experienced the sensations which she has now; but in her first pregnancy she had a discharge of a semitransparent fluid for about a month before delivery.
March 28th. Mr. Taylor sat up with her all night, at her request. On examination, the cervix uteri was found elongated, and the os uteri was alternately dilating and contracting; at every dilatation the patient lost at least a pint of clear fluid. No part of the child presented, and no resisting tumour could be felt on pressing the abdomen. Two injections were administered, as well as a dose of castor-oil; and on the following night a sedative was given.
July 25th. The patient continued her usual avocations, though the fluid dribbled away, until today, when Mr. Taylor was again called to her at half-past twelve P.M. She was suffering from regular labour-pains, after which she expelled a quantity of fluid. She would not consent to an examina
tion per vaginam.
26th. The pains still continue, followed by a gush of fluid.
28th. On examination per vaginam, the head of the child was plainly to be felt presenting at the brim of the pelvis. The pains continued, though neither so strong nor so frequent, and the fluid was continually dripping from her till
August 9th, when she was delivered of a small female child, at half-past two A.M. As the placenta was not expelled by the natural efforts, Mr. Taylor passed up his hand at five o'clock, when he found it attached to the uterus by a few fibres, which were detached with great difficulty and much suffering to the patient. She was ordered not to be moved, as there was some hemorrhage, and the uterus did not contract, and to have nothing but cold toast and water.
11th. Much better. The pains are still very severe, and are increased by pressure. Pulse soft, and rather quick; the bowels have not been open since delivery. She was ordered to be fomented, and to take an aperient.
12th. Can bear pressure on the abdomen, but complains of a tightness about the head. The milk begins to flow. Bowels regular; pulse natural; tongue clean, and moist.
She continued to improve, and before the end of the month was able to do her household work.
Observations. The above case was attended and reported by Mr. Taylor, excepting that I examined the patient the latter end of March, after he had been up with her a few nights before. She imagined that she had become pregnant in August 1824; but she was probably mistaken, as she experienced a discharge of blood three months afterwards,