Case. J. M'Clusky, aged 11 years, of scrofulous habit, labours under considerable swelling of the abdomen, with fluctuation and tympanitis. "The right hy pochondrium appears rather full; upon examination, the liver can be felt extending across the left hypochondrium, and as far down as the umbilicus, presenting a defined edge." He had oedema of the left leg-no cough or dyspnoea-good appetite-much thirst-urine copious-lightcoloured-and depositing albumen in abundance when heated. Bowels are regular, the pulse 125, tongue clean and moist, sleeps well. The complaint was of twelve months standing. One grain of calomel was ordered to be taken every night, and some mercurial frictions to the right hypochondrium. On the eighth day of this treatment, the mouth was affected, and the calomel was omitted. Having caught cold, a smart ophthalmia occur red, which required leeching, &c. Afterwards, as the swelling of the abdomen continued, the calomel was renewed, in two grain doses, and half a dram of the spir. æth. nitr. was given twice a day. The belly became reduced in size-the urine more copious, but still coagulable by heat. In a short time afterwards, he was discharged, the abdomen being nearly reduced to its natural size, and the appetite good. The following extract from the observations appended to this case, we deem worthy of insertion.

"It is not easy to determine the nature of the hepatic tumour which was so very considerable in this boy. It was slow in its increase, and not attended with well marked symptoms of chronic inflammation of the liver. There was no tenderness on pressure, nor any pain or uneasiness in the right hypochondrium. There was 'no evident derangement of the biliary secretion, and his appetite, sleep, strength, and nutrition, were scarcely impaired. On the other hand, the oedema of the left leg, the commencing ascites and tympanitis, the albuminous urine, accelerated pulse and increased thirst, all united to prove that the constitution had begun to suffer in consequence of the diseased state of the liver. The alterative doses of mercury, which were cau tiously exhibited, were evidently pro

with spirit of nitrous æther seemed useful in relieving the Tympanitis. In this, organic alteration had taken place in the and many other cases, where considerable liver, we have observed an apparently Thus we have healthy secretion of bile. found bile of an healthy colour and consistence in the gall bladder, when the substance of the liver was tuberculated charges therefore furnish no proof that throughout. Naturally coloured alvine disextensive organic disease of the liver does not exist."

"Concerning the albuminous state of the urine we may remark, that it is no proof of an inflammatory condition of the constitution, it merely indicates considerable disorder of the function of assimilation. In health, a certain portion of animal matter is contained in the urine, in the form of that highly animalized substance, urea. This may be increased so much in quantity above the healthy standard as to constitute a disease. When the assimilative powers are more deranged, the animal matter of the urine ceases to assume the more highly animalized form of urea, and is voided in the form of albumen, which contains much less nitrogen than urea. In a state of the system still further depraved, it passes off in the form of sugar, which contains no nitrogen, and is the least highly animalized. In diabetes, it is probable, that the urea is voided in increased quantity at first; as the disease proceeds the ani mal matter is voided in the shape of albumen, and afterwards of sugar. When diabetic patients are getting better, then the contrary seems to take place; and when the sugar diminishes the albumen increases or reappears, and afterwards is replaced by the more healthy secretion of urea. Doctor Prout was the first to establish the existence of these three dif ferent species, or rather stages of diabetes. In dropsy the appearance of albumen in the urine is a bad sign, as indicating a depraved assimilation and a source of debility. We have established, by numerous experiments, that when there is much albumen, there is scarcely any urea in the urine, and vice versa, or more generally that the proportion of urea is inversely as that of the albumen. How far the treatment suited to diabetes may be also applicable to cases of chronic dropsy with

We believe that none, even of our continental brethren, have taken greater pains to investigate the causes, the seat and the consequences of fever, than the two physicians above-named. Their sentiments, therefore, on the pathology of this wide spread disease must be interesting to the profession at large. These sentiments may be gathered from some observations appended to a case of fever (among many others) treated in the Meath Hospital.

"The epigastric tenderness, with nausea and vomiting, so common in this fever, seemed to be caused by inflammation of the mucous membrane of the stomach. In most of the fatal cases this was found of a dark-red colour and very soft, a condition evidently produced by violent inflammation. In others the redness was not so extensive, dark, or continuous; although we acknowledge, that in the present fever the above symptoms, depending on inflammation of the stomach, are very frequent, yet we have seen some cases where there was no evidence of any local inflammation whatsoever; and in others again, have observed that some other organ, as the brain or lungs, was the seat of inflammation, while the stomach was free. We cannot subscribe therefore to the opinion, which supposes a local inflammation to be the root of all fevers, or to that which attributes their origin solely to inflammation of the mucous membrane of the stomach and alimentary canal. In our dissections we have in some cases found the brain inflamed, in more cases the lungs, and still more some part of the digestive organs. We do not recollect to have found in one instance, out of very numerous dissections, a fatal case of fever which

did not exhibit some serious local lesion of an inflammatory nature; so that while we deny, from our observation of cases during life, that fever necessarily implies local inflammation, dissection has convinced us that the occurrence of local inflammation during fever, is the general cause of its fatal termination. Let us here observe that the latter inference is by no means contradictory of the former; for in the fatal cases, accurate observation always detected, during life, the seat of the inflammation; so that in those cases which terminated favourably, and where no such symptoms existed, our inference that no local inflammation had been present, receives additional strength from our post mortem examinations, for there we always found inflammation where we expected to find it; that is to say, we were always able to pronounce on its situation, so far as to tell, before the body was opened, in which cavity the inflammation would be found. The post mortem examinations have been always conducted by ourselves with the greatest care, and we generally spend between two and three hours in the examination of the body, being convinced that nothing has contributed to retard the advancement of medicine so much as superficial post mortem examinations. In examining the abdomen, we first note the general appearances of the intestines, and then take out the whole intestinal tube, which we slit up with an enterotome at its mesenteric attachment; this is done in order to avoid dividing any of the follicular patches or ulcerations in the small intestines, which are always situated at some distance from the mesenteric attachment. During this process we examine the contents of the alimentary canal; and afterwards having first carefully washed the mucous membrane, we remark its appearance throughout its whole extent from the stomach to the rectum. morbid anatomy of the brain, the lungs, and the intestinal canal, has, within these very few years, received so many important additions, so much light has been thrown on this subject by more accurate investigations, that we would hesitate much in drawing any conclusions from the dissections of fever subjects recorded before this period. Indeed, we could prove that in most of even modern works on the pathology of fever, morbid appearances have been frequently mistaken, and more especially that many things, both

The

in the brain, lungs, and alimentary canal, have been set down as morbid, which really are not so; consequently, conclusions, not at all justified by the state of the parts, have been drawn. Thus, we hear of sanguineous congestion in the head, and morbid vascularity of the brain, intestines, &c. where the very accounts given contain internal evidence, that these supposed morbid appearances had either no claim to that appellation, or resulted from changes which took place immediately before or after death. In fact, we look upon the morbid anotomy of fever as a subject which requires to be investigated almost de novo. Our assertion, that we have hitherto found evident lesions of vital organs in all the fever subjects we have dissected, is, we are aware, opposed to the recorded experience of many authors, who relate numerous cases in which no morbid alteration of any consequence could be detected. We question however very much the accuracy of such dissections, for, as has been well observed by Rostan, nothing is easier than to find nothing. We doubt whether such persons have injured medical science more than those who have found too much."

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knife, but only made a flesh-wound over the crico-thyroid membrane, which was slightly perforated. Through this aperture the woman breathed, when Dr. Cullen saw her two hours afterwards. wound was not of much consequence in itself, but the patient was in an unpleasant condition in other respects. was slightly delirious-dwelling on her domestic grievances--pulse small and feeble-face flushed-tongue white and tremulous countenance expressive of anxiety and suffering. The wound was dressed-the head shaved-and ice applied to the scalp. Some wine and water was given to her, when she was disposed to sink-a cathartic was administered, and she was confined in a dark room. She passed a quiet but sleepless night, and next day had cough. Delirium returned in the evening. Leeches to the temples and forehead. Third day. Rather better-cough, with difficult expectoration. In the evening, the stethoscope detected inflammation in the smaller branches of the bronchia A large blis ter to the sternum. Fourth day. Delirious, probably from agitation at seeing her husband. Fifth morning, early, she was reported to be dying. Dr. Lubbock, the house-surgeon, found her on the point of suffocation, with death-rattle in the throat-livid face-cold extremities. Dr. L. quickly introduced a large curved canula into the wound, which enabled the patient to take a deep inspiration, and the breathing immediately became easier. She now brought up a quantity of mucus through the canula by a process which Dr. C. will not allow to be exactly coughing. The alarming symptoms soon subsided, and the expectoration became free. The same train of dangerous symptoms again occurred in the evening from the slipping out of the canula, but were again relieved by closing the opening in the larynx, and inducing the woman to cough up the mucus by the natural passage. This, however, had but a temporary effect, and she died the same night.

Dissection. The vessels of the brain were found much injected, with considerable effusion in the sub-arachnoid cellular tissue. There was no disorganization of the substance of the brain, but there was much serum in the ventricles and at the base of the brain. The bronchia, especially on the left side, were obstructed with bloody mucus-the lungs sound.

The mucous membrane, in the neigh bourhood of the wound, was inflamed but not thickened. There was no effusion into the submucous cellular tissue, and, consequently, no diminution of diameter in the glottis. The membrane of the trachea and bronchia was highly inflamed. -ED JOURNAL.

Dr. Cullen seems to think that this poor woman's death was occasioned by the state of the air-passages. But we imagine the phenomena presented in the brain were more likely to occasion the fatal event. The case, however, has been evidently brought forward to illustrate some observations made in a preceding number of our Northern contemporary, on the difficulty which a patient has in coughing up, or rather expectorating the phlegm, after bronchotomy. Indeed, it is probable that, had it not been for some observations which we made on Dr. Cul

len's paper, this last case might not have seen the light. We said that a patient can cough-that is, forcibly expectorate through a tube in the trachea. Dr. C. maintains that is not coughing, strictly speaking. We will not quarrel with the learned Doctor about the name of process; but, having seen a patient cough for weeks and months through a canula, we cannot give up the evidence of our senses, even to support an ingenious hypothesis. If Dr. Cullen will look into the 5th volume of the Medico-Chirurgical Journal and Review, for January, 1818, he will there see the case of Mr. Price, of Portsmouth, who, to this day, breathes through the tube. Dr. C. will see the diurnal details of the case, where the act of coughing is every day stated-and where, on the 55th day after the operation, the following passage occurs :"Last night he felt a piece of bone (ossification of the thyroid cartilage) fall down into the lungs, and has ever since been in a dreadful state of coughing. He feels the piece come up to the tube, but, as he cannot get it out, it falls back, and keeps him in constant agitation." A large canula was quickly constructed, and forced into the aperture, and, "shortly afterwards, in a violent convulsive cough, he threw out the piece of bone (No. 1) quite across the room where he was sitting." P. 6. Now we think Dr. Cullen will absolve us from the charge of forging a case ten years ago, and putting down expressions that were to contradict his VOL. VIII. No. 16.

After this theory at the present time. document, we leave him to persuade the world, by words, that a man cannot cough after a tube has been introduced into the trachea.

5. GLASGOW INFIRMARY-HOSPITAL OF SURGERY, &c.

PULSATING TUMOURS OF THE SCALP.

The first case which we shall notice, occurred to Dr. Maclachlan, one of the surgeons of the Glasgow Royal Infir mary, and is related by that gentleman, in the first number to the Glasgow Medical Journal.

The patient, a discharged soldier, æt. 30, applied to Dr. M. with a tumour on the left side of the scalp, presenting the following appearances :

"Soft, puffy, pulsating, and somewhat elastic swellings of a varicose appearance were found to occupy the course of the temporal, posterior auris, and occipital arteries and their principal branches; each branch terminating by a tortuous extremity. These swellings could be made partly to disappear on pressure, but on its removal, they speedily regained their former volume. They pulsated throughout their whole extent, and the pulsations were synchronous with those of the heart. By pressing on the common carotid, the pulsations ceased all along the swellings; and, by intercepting the flow of blood through the temporal or posterior auris, the throb was interrupted in corresponding parts of the tumour. They were not painful on being handled, but he complained much of the torture he had experienced for the last two months, from the throbbing, which often deprived him of rest for nights together, and, as he said, made his existence miserable to him. The integuments covering the swellings were of their natural colour; only at those points which were most prominent, they had a slightly blueish-red tinge.

"This arborescent tumour commenced in front of the ear, immediately over the zygoma, and quickly swelling out, it be came of the size of a split lemon, lying transversely over the ear. It sent a pro

cess forwards on the forehead, communicating by a tortuous extremity with the 64

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supra-orbitary twig from the internal carotid; a large process upwards to the crown of the head; and backwards, the main body of the tumour communicated with the puffy swellings of the posterior auris and occipitalis, which latter vessels gave a varicose feeling to the scalp over the left side of the occiput.

"The largest and most prominent part of the tumour was immediately over the ear at this point, the throbbing was very violent, and the integuments being very thin and rather pointing, it threatened ere long to burst."

Ten years previously the temporal artery had been opened, and a small aneurism formed upon it. For this the vessel was cut across, but without success, and a ligature was then applied. The little tumour disappeared for a time, but afterwards returned, though for the first five years it gave him little uneasiness. Pressure had been already employed, and the patient would not again submit to it, but wished his carotid artery to be tied. Dr. M. however, proposed taking up the vessels separately that fed the tumour, and, if this should fail, tying the common carotid. Accordingly, assisted by Professor Towers and Dr. Anderson, he exposed the temporal artery, as it emerges from under the parotid, and found the vessel larger than a goose-quill, thinner and more diaphanous in its coats than a vein, and pulsating with much violence. A ligature was applied upon the vessel, with a compress and bandage for additional security. Pulsation ceased in the anterior and central parts of the tumour, which felt flaccid and doughy, but, Dr. M. not liking the state of the vessel, determined on securing the carotid, which was done next day in the presence of Professors Burns and Towers, Drs. King and Anderson. The steps of the operation, which was performed on the 10th July, we need not describe, but, immediately after its completion, the tumours of the head felt flaccid and lost their pulsation, although they were but little diminished in size. Next day he was seized with pain in the right side; pulse 120; skin hot. V. S. at two bleedings, to 70 0%. Saline purges-a blister. 12th. Pain of chest easier-breathing oppressed. Tinet. digital-anodyne at bed-time. 13th. Much the same, but, in the afternoon, there came on pain in the region of the liver, in

creased on pressure. V. S. ad 3xxiv.— castor oil-turpentine enema―-anodyne. 14th. Delirious-respiration oppressedpulse 144, feeble. Died at 5, p. m.

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Sectio cadaveris, fifly hours after death. -In consequence of the heat of the weather, putrefaction had made some progress. There was some pus in the anterior mediastinum, and about a pint of greyish muco-purulent matter in the right cavity of the pleura, with a little bloody extravasation into the left. wound had adhered by the first intention, but was partially opened up by putrefaction. The carotid artery appeared to be quite sound in the neck-small clots had formed above and below the ligature, and the artery was puckered from the recent deposition of lymph. Its inner coats were divided, its external entire, but below the ligature the inner coat was of a vermilion tint, as was that of the thoracic aorta. The aortic arch between the heart, and the giving off of the left carotid, was healthy. The temporal and other branches of the carotid in the head "had degenerated into dilated tubes of great thinness and transparency," and had become elongated, contorted, and convoluted on them. selves, so as to form, by this species of doubling, the tumours which constituted this singular disease. Where the thinning of the branches began, or whether the internal branches of the carotid had suffered also, giving rise to the epileptic fits to which he had recently become subject, Dr. M. was prevented from ascertaining.

Dr. Maclachlan thinks, and so do we, that there is an obvious difference between this species of pulsating tumour, and the aneurism by anastomosis described, by John Bell, as a congeries of active arteries, absorbing veins, and intermediate cells." Two cases are given by Pelletan in his Clinique Chirurgicale, precisely tallying with this. One patient was a girl of 18, on whom compression was tried, but she could not bear it. He then tied the temporal artery, and with good effect, but the patient died of "indigestion." Upon dissection, the tumour was found to consist of tortuous and dilated arteries. Boyer, Pelletan, and others, are of opinion, that the disease is congenital, but without sufficient grounds. Dr. M. himself opened the temporal artery in the first instance, and, at