626

lead ointment and alkaline lotions, with the internal use ofiodide of arsenic; while, in eczema, the value of cod-liver oilis also beginning to be almost universally conceded. Dr.Addison, of Guy’s Hospital, in opposition to more commonopinions, believes that much of the obstinacy of eczema de-pends on its being infectious, though the dermatologists doubtthis fact. Opium, as continued to be used by Mr. Skey veryextensively in all kinds of indolent ulcers, especially those ofthe lower extremities, has lost none of its prestige in thesecases. Creosote, made into pills, with liquorice powder, (theonly mode, it is said, of forming it into pill mass,) has alsobeen found very valuable in various skin affections; especiallythose of the cancroid character. Turpentine also, appliedexternally.In the case of a man suffering under the effects of several

spreading sloughing ulcers on both thighs, the result of theartificial inoculation of syphilis matter at the Lock Hospital,Mr. Stanley directed the attention of his class, in November,to the peculiar character of these sores, and ordered the ex-ternal application of the old " Priars’Balsam" (tinct. benzoin co.),which he said he had found the best of all the usual remedies forsuch affections. The man has been rapidly improving.In a second case of syphilitic psoriasis, Mr. Stanley re-

marked to his pupils, that iodide of potassium and sarsaparillawould, in appearance, cure the disease for a time; but, as amatter of certainty and safety, he always preferred, wherethis affection was very well marked, to see it disappear underthe effect of mercury; the patient was accordingly orderedthe compound calomel pill, night and morning, (Plummer’spill,) and if it affected the mouth so much the better, thoughthe action on the mouth is not necessary, if the sores begin toheal without this change; salivation being only one effect ofmercury, the healing of the sores another, but one moreessential.

Oxide of zinc, as the best medicine in chorea, and oxide of Isilver or oxide of zinc, in some forms of epilepsy, have beenextensively tested in numerous cases in all the hospitals; oxideof zinc especially, by Dr. Hughes, as noted at Guy’s, in morethan 200 cases. A syrup of iodide of zinc, as ordered by Dr.Barlow, at Guy’s, is perhaps the most agreeable form of themedicine. We have observed both Dr. Todd and Dr. Addisonrecently dwelling, in clinical remarks, on the necessity of notmistaking hysteria for epilepsy, the chief difference being, thatin the latter the loss of consciousness is extreme, but not so inhysteria. In all else, however, the two diseases are apparentlythe same, and are very often mistaken the one for the other. Wehave "half a thousand shades of epilepsy," according to thelatter physician; while Dr. Todd has found cases of "incurableepilepsy" which resisted oxide of silver to be, on further exa-mination, hysteria. All these cases agree in leaving little orno organic lesion by which they might be localized. Chorea ismost common, in all the cases seen at hospital, between theage of nine and fifteen, and is most frequent in females. Theupper extremities are more affected than the lower, thuspointing to emotional and reflex influences.The physiology of sugar in the system has recently undergone

so many changes, that diabetic sugar in the urine in patientsattracts unusual attention. A case of this kind has been underthe care of Dr. Bence Jones, at St. George’s, for some weeks;and as this physician shows his class, week by week, thechanges in the amount of sugar, resulting from changes inanimal and vegetable diet, treatment, &c., and explains thecopper and other tests for glucose, such patients possess no un-usual interest for students. Diabetic sugar is never generatedfrom milk sugar, though it need scarcely be remarked it isquickly formed from other products very nearly allied, such asalbumen, starch, or vegetable sugar. Diabetes is more underthe control of regimen than medicine. Milk is a very properdiet for diabetic patients. Dr. Bence Jones observed in thiscase, though milk abounds in sugar, some physicians, since theresearches of Bernard and Lehmann, seem inclined to look onthe disease as not so much a new formation of sugar as an ac-cumulation of that always forming in the normal state, and insome way obstructed in its exit, like urea or bile detained inthe system. Dr. Pavy, of Guy’s, believes he has found thatdiabetic sugar is a specific form, different from other modifica-tions of glucose. It seems very well established, that the sugarof the liver is formed from the albuminous products of theblood of the portal vein; and still more recently it has beenobserved that fibrin and hsematin, disappearing, also, in theliver, whether as the result of tuberculous or inflammatorycrases of the constitution, may give rise to sugar. Some otherrecent researches would point to diabetes as a peculiar form ofnervous disease, rather than a renal or hepatic affection, the

kidneys only acting in a secondary point of view. In hospitals,also, it is sometimes found that albumen and sugar alternate in thesame urine, still further indicating a connexion between thesetwo substances in the portal system. Amongst recent remedies,gluten bread has been much recommended, but fine bran breadis preferable. Maccaroni is also highly praised. Amongstmedicines, citrate of ammonia and opiates are perhaps the best.The very great usefulness of the liquor ammonise acetatis, in

cases of Bright’s disease of the kidney, deserves to be moregenerally known than it is. We sometimes see this affectiongiven up as beyond all cure; yet at Guy’s Hospital, where theaffection was first discovered, and since then has been mostcarefully studied, Dr. Addison has found the liquor ammoniseacetatis, by acting on the skin and relieving the congestedcondition of the kidney, the best of all the remedies for thisdisease; diuretics at the same time to be strictly avoided, butnot mercurials.The use of setons, though almost exploded in diseases of the

joints, is found to be very beneficial in the shape of thin singlefilaments of gutta percha, or some other substance not per-meable to pus, in chronic inflammations of the eye. In casesof obscure melancholia, a seton to the nucha sometimes actsalso like a charm. Some extraordinary uses of iodine havebeen referred to in hospitals, but it requires greater courage,perhaps, than discretion to adopt them. A case, diagnosticatedas hydatid cyst in the thorax, recently described by Vigla,was punctured, giving exit to hydatids, and the sac subsequentlyinjected with iodine. The patient quite recovered severalmonths after.

In more than one case of hydro-pericardium the fluid hasbeen let out in French hospitals, and tincture of iodine injectedwith good effect. In a case of this kind at St. Mary’s Hospitalit was deemed a very dangerous experiment to puncture thepericardium at all, while the uses of iodine have been limitedto injecting abscesses on the surface, ovarian cysts, and hydro-cele, in all of which it seems to answer better than any othertherapeutic agent. In a case of ovarian cyst at St. Mary’sHospital, where Mr. I. B. Brown followed up paracentesis ofthe cyst with tincture of iodine injection, more than a yearsince, the result has been very encouraging, as the womancontinues in good health, the tumour having only refilled to avery insignificant extent. In a somewhat similar case, Dr.West, at St. Bartholomew’s, remarked, that it was somethinggained during the year, that we had at length a remedy inthese cases that did not effect positive mischief, and as such,iodine deserved very general confidence.

ON THE SPECIAL STUDY AND TREATMENTOF PHTHISIS.

BY JAMES E. POLLOCK, M.D.,ASSISTANT-PHYSICIAN TO THE HOSPITAL FOR CONSUMPTION AND

DISEASES OF THE CHEST- BROMPTON.

THE propriety of the separation of certain special chronicaffections, for the purposes of their peculiar study and treat-ment, has for some time past occupied the attention of the pro-fession. The experiment has been largely tried in this country,and is daily undergoing further extension. We have, there-fore, the results of some years’ experience now before us. The

arguments for and against these institutions are derived fromtwo natural considerations ; the one has relation to the advan-tages or disadvantages to the patient, from being placed injuxtaposition with others similarly affected ; the other regardsthe position of the medical attendants, who, while they havepeculiar facilities for the study of a disease whose numerousfeatures, as varied by constitution, age, and sex, are exhibitedin a vast number of cases collected together, have, on the otherhand, to undergo the danger of receiving, from the very isolatedcharacter of their study, a bias in judgment, and a consequentnarrowing of those general views of disease which distinguishthe cultivated physician. We would direct some brief obser-vations to both these very important questions.The first class of arguments has relation to the patient. It

has been asserted that the grouping of such cases as chronicphthisis together in one building, associated in their habits,breathing the same atmosphere, and having in common suchpeculiarities of symptoms, that a comparison, depressing in itsmoral results, is almost forced upon them, has a directly inju-rious effect on the nervous system, insomuch as it lowers that

vital force and mental resistance which the physician so much! desires to enlist in favour of his curative efforts in chronic cases.

627

These arguments must be tested by the results of treatment, forif the ratio of cure and improvement is greater in the hospitalthan in cases not so placed, We have strong reasons for doubt-ing the reality of these depressing influences. On referring tothe published report of the Brompton Hospital, wehave reason.to believe that they have had no appreciable injurious effect on_the treatment ; while, on the other band, the cases admitted"have exhibited the usual improvement which all chronic affec-tions in persons of the lower class of life undergo when placedin circumstances of hygiene so vastly superior to that affordedby their own dwellings and limited pecuniary means. In otherwords, diet, well warmed and ventilated apartments, cleanli-ness, and the removal of the harass of providing for dailywants have had their usual and acknowledged influences.

-TABLE showing the Per-Centages of the Results in each Stage ofthe Disease, in 535 Males and Females (In-Patients).

(For the sake of clearness, the fractions are omitted.)

Fi1’st Medical Report of tlae Hospital for Consumption, bythe Physicians of the Institution. 1849. p. 34.

The questions then remaining are, whether the respirationof the same air and personal contact have appreciably injuri-ous results on the system; and if the nervous moral effects.are found by experience to injure the patient.

The system of ventilation which is now so perfectly carriedout at the hospital at Brompton, ensures such a constantchange of atmosphere throughout both wards and corridors,that anything like stagnation is impossible. It is no longer aquestion as to the number of cubic feet allotted to each patient-a method of calculating the allowance of air per headwhich has always seemed to the writer to be founded on falseapprehensions of the respiratory process on one hand, and ofthe perpetual changes in the atmosphere caused by tempera-ture and the necessary alterations in its density on the other.The cubic capacity of a diving-bell, constantly supplied witha fresh current of air pumped in, (the excess escaping underwater,) is not the measure of the volume of air consumed byor requisite for the man inside it. The extent of air-filledspace immediately surrounding him is of no importance, pro-vided that air be changed with sufficient frequency to removethe impure products of respiration, and to supply enough ofatmosphere for further use. We are all familiar with theapparatus used by the diver, where a helmet supplied with airgives sufficient respiratory space. The true value of space inan apartment is, then, to be measured by the actual purity ofits contained air, and that purity is only attainable by a con-stant change so long as we alter its materials by respiration orcombustion. A chamber of moderate size, with a current ofair, will answer all purposes if the air be changed often enough.The inconveniences of a small space for this necessary changeare that the current is perceptible, forming what we call "a adraught." In the helmet of the diver this " draught" is a I

blast; in the properly arranged ward it is imperceptible, though I

constant. The value of the space, then, which surrounds a ’,sick bed, (the room being fully ventilated,) is that the sensa- ition of a current of air, and its ill effects are no longer appre- ’’,ciable. Where there is no regulated current, the patientrespires again and again nearly the same atmosphere, which Ifinally becomes surcharged with impurities. Now, in the Ihospital at Brompton, in addition to the wards being spacious,there is a regulated and constant supply of warm air, whichpasses through the chamber around its walls, and issues byappropriate vents, both near the roof and the ground. Thetemperature is about 64°, summer and winter; the corridorsand passages are all supplied in the same manner; the doors ofcommunication are open, and thus an atmosphere is constantly, I

though imperceptibly, chsaging, and at a regulated tempera-ture, pervades every portion he building.The possible injurious effects of contact, involve another

question on which the profession i& scarcely unanimous, al-though the majority in this country seems opposed to thetheory of the contagiousness of phthisis. ,

In diseases of acute character and of marked intensity, wefind a difficulty in obtaining positive evidence of contagion,even although certain localities of defined extent may alonebe attacked, and the invasion and progress of the epidemicmay have been noted with peculiar care. An increased diffi-culty manifestly attends the investigation of the possible effectsof contagion in phthisis, its attack being insidious, its progressslow, and its localization indefinite; while the circumstances,such as impure air, poverty, deficient food and clothing, andcertain occupations which are supposed to prepare the systemfor the disease, are of universal prevalence as regards time, andform the inevitable features of civilized society everywhere.Again, in the cases which seem to favour the theory of contagion-as when the wife or parent, from attendance on the husbandor child affected by phthisis, are attacked by the disease them-selves-we have, in addition to the manifest tendency totubercle which blood relationship gives, (where it exists,) anaggregation of the very circumstances which notoriously pre-dispose to an attack-anxiety, night-watching, irregular andhasty meals, deprivation of fresh air, and a mental concentra-tion on every feature of a slowly-destructive malady. In theabsence of positive proofs of contagion, and in the presence ofnumberless facts proving its spontaneous origin from constitu-tional causes, we must act up to the present limits of our know-ledge, and not deny to the afflicted the many advantages whichhospital treatment affords. The presumptive evidence is alsoas yet against the theory of contagion, inasmuch as we arestill unacquainted with any chronic malady which is unmis-takably communicable by anything short of inoculation witha virus, and exceptions of this class are probably confined tosyphilis, porrigo, and psora. The moral effects of aggregationdeserve our serious consideration, and although they muat havesome effect, we are inclined to believe that practically theyare much less than we could have previously anticipated. Itis even doubtful if they are greater than in general hospitals.The curative progress of the cases is hopeful and satisfactory;the relief obtained fiom distressing symptoms is at least large,and the mortality decidedly smaller than even the advocatesof the hospital anticipated. To a visitor (and many such haveexpressed their pleasure and astonishment) the aspect of thehospital at Brompton has little of that depressing characterwhich the presence of unrelieved and hopeless disease conveys.In addition, the mental state of the phthisical is proverbiallysanguine and hopeful.

It is, however, with a view to an impartial consideration ofthe second argument, which is fraught with questions of thedeepest pathological import, that we would now turn. Doesthe minute and careful study of any systemic disease with thelight of modern investigations, and by the means and appliancesof modern chemical and microscopical methods of research, tendto contract or to expand the general view which the enlight-ened pathologist is forced to maintain, if he keep pace withthe light which is now dawning on medical investigations ? Isit possible so to limit and localize diseased action, that its studycan be confined to the organ in which immediate evidence ofits presence is found ? Is the measure of its importance to betaken from the extent to which morbid organic products areevidenced :-or have we not rather arrived at a period inpathological science when vital phenomena are estimated as ofvastly higher importance than any individualized lesion, thelatter being purely indicative, the former the source and ele-ment of departure from health, to which the local symptomshave led up in a series of morbid processes ? These are im-

portant questions, and if answered in favour of the general, asopposed to the local origin of disease, must go far towardsdivesting the study of special disorders of that contracted cha-racter which it formerly possessed. It is not true of any of thegreat masters of auscultation, from Laen nee and his philosophictranslator down to the present generation of chest pathologists,that they have ever estimated the value of physical as at allequivalent to that of the vital signs of tubercle in its origin, itsdevelopment, or its progress. The stethoscope has ben freelyaccepted as an assistance, but it is only the ignorant who haveventured to weigh present or predicate future danger by its un-assisted use. The works of Louis, Laennec, Forbes, Williams,and Stokes are full of warnings as to this possible abuse ofauscultation, while the students of chest disease may well beproud of the large pathological views which distinguish every

628

?age of these authors from the writers of treatises, composed)fpoor sketches of local symptoms or physical signs.The pathology of phthisis, or of tuberculosis, is intimately

connected with some of the most deeply-seated blood changes;nor is it possible, in the present state of our knowledge, tolsolate it from a host of other kindred affections. The Germanpathologists have traced it to be a true fibrin disorder, connectingits origin with changes in the blood itself, leading to an excessof this principle. But whence the excess ? Is it traceable tothe interruption of certain oxydizing functions carried on byEhe lungs, the liver, or other organs, or to the removal of otherconstituents of the vital fluid, which leave the fibrin in coin-parative excess ? Has muscular waste led to a hyper-fibrinated Iengorgement of the entire capillary system, and has the lung-itself the centre of the system-only suffered first in themorbid action which has led to a perversion of a vital andorganizable plasma into a morbid and aplastic exudation ? Hasthis exudation, with almost invariable tendencies to decay,itself furnished food for further blood contamination, and soadded morbid material for a second and third attack of tubercle ?We care not, for the sake of this argument, if these views betrue or false; but they are afloat in every mind at this moment-over-argued, and too much insisted on by some it may be-but urged on the consideration of pathologists by masterlyminds, and arguments of striking depth and diffusion. Theyat’least demand a settlement by our investigations rather thana setting aside by theorists. The student of tubercle then nolonger approaches a disease to be learned by a few mechanicalsounds, and summed up in a succession of easily recognisedsymptoms; he has to look deeper, and regard the evidences ofblood disorder in altered secretions, in exaggerated waste of thefibrous tissues, in vital changes of nutrition, which constitutean antecedent disease, of which the deposit in the lung is but asecondary degree and a consequence.

- - - -- -

Whether viewed in a diagnostic or a remedial light, thesetheories are pregnant with practical import. By them alonecan we explain the apparent anomalies of tubercular develop-ment and progress. By considerations of the meaning of vitalchanges in the blood can we alone understand how the firststage (so-called) of tubercle may remain an almost latentaffection, evidencing a partially altered state of blood, which,owing to some improvement in quality, has stopped short of ’,its secondary stages, and allowed the local mischief to remainas harmless in its general effects as a pleural adhesion of similarextent. By close observance of the vital resistance to diseasewhich some subjects exhibit, (in itself an evidence of onlypartial contamination of the fluid which is furnishing thenervous centres with nutrition,) we are enabled to predict atoleration of the morbid affection in the lung, if not its cure, insome rare cases. Is it not notorious, that with the ready appre-ciation of active nutrition and unimpaired vital force which along face-to-face acquaintance with the aspects of disease givesto-some of our most skilful physicians, they are able to pronounceon the likely progress of a case with far more precision thanthe stethoscopist, who measures life-chances by the amount ofvocal resonance in the chest ?

Again, if our progress in remedies is to keep pace in anydegree with our pathology, from. whence are we to look-fromwhence do we look for improvements? Is our trust any longerin. local depletians or counter-irritants, in inhalations, or inpossible or impossible expansions of the lung-tissue bymechanical means ?-In the change of air which is to heal upthe ulcer, the astringents which are to control the purulentsecretion, or the absorbents which are to remove the tubercularmass ? An enlarged pathology has led us up to higher views,not, indeed, despising some of these as adjuncts, but aiming atan improvement of the blood itself, and of the vital process ofnutrition in its largest sense, we are attempting, and not un-successfully so far, to furnish that which the blood wants, andto alter its hyper-fibrinated condition. The action of animaloils, however inexplicable, is surely an advance towards apurer system of therapeutics.

These views are offered, not so much as a sketch of thepresent state of the pathology of tubercle, as the future towhich every earnest student must look for its improvements.

IThey require and demand research. A deeper study of symp- Itoms, with reference to their vital import, will most probablylead to the recognition of blood-changes in their earliest phase;while the investigation of alterations in the excretions, in thepuhnonary exhalation, in the functions of the skin and kidneys,must form the groundwork of our improved pathology, and isalready affording a harvest of unsuspected facts. It seemsvery evident that any advance in our knowledge of tuberculosisis to come in this direction. It is not likely that any material

improvement will ever take place in our knowledge of physicalsigns. Those of which the true value is already ascertainedare amply sufficient, in skilful hands, to confirm a diagnosisfounded on vital changes. For the last fifteen years we havenot added one sign of much value to those we already possessed.Some late observations by the writer, at the Brompton Hos-pital,* have confirmed the relative value of the ten indicationsof consolidation of the lung best known to the profession.Their order of merit may be equally well seen in Fournet’sessay, published in 1840, with the exception of one of verydoubtful origin, (the "wavy inspiration" pointed out by Dr.

I Theophilus Thompson. )Again, microscopic researches which point in the same

direction, and attempt the recognition of tubercle when de-posited and expectorated, however valuable as adjuncts, cannever resolve the question of the origin of tubercle, or, per se,give to science a method of recognising the antecedent blood-changes. The microscopist must begin higher up, and attackthe blood itself, the tissues, and the excretions; and here,indeed, with the aid of chemical analysis, there is a wide fieldfor observation and discovery.With these views, we think it may be maintained with con-

fidence, that the study and treatment of phthisis comprise alarge opening for pathological research; that its analysis in.volves an acquaintance with every form of disordered function;and that, as advances in our knowledge are alone to be obtainedor expected in this direction, it is little likely that our specialinstitutions are to sink into sanatoriums for chronic disease,where the stethoscope is the measure of the danger, and theonly indication for cure. If, on the other hand, the patho-logical outline which we have here sketched be not entirelyrecognised, or even opposed, by some of those engaged in itsstudy, here is still further evidence of the impossibility of onedoctrine taking possession of any enlightened set of observers;and in the presence of discussion, founded on the evidence oflabourers in the same field, may we not obtain much hopefulindication of life and progress and enlargement, if not of finaltruths, for ourselves and those who are to follow us ?

This apology for the study of special pathology has, therefore,for its foundation, the broad basis of the impossibility oflocalizing disease. As long ago pointed out by Mr. Travers,there is not even a surgical injury without vital influence, andwhat is termed "constitutianal irritation. " The other argu-ments which seem to follow on this are manifest. If we excludenarrow views and one-sided aspects of disease, the study 6fpeculiar affections, in a metropolis of nearly 3,000,000 of people,becomes only a necessary subdivision of labour, and is as con-venient as the other arrangements of the profession, by whichmedical and purely surgical practice are placed in differenthands, while our education and our pathological advances gahand in hand.

Chandos-street, Cavendish-square, Dec. 1855.

REPORT OF A

CASE OF CAULIFLOWER EXCRESCENCEOF THE UTERUS.

BY B. J. BOULTON. M.D., Horncastle.

MRS. R——, aged forty-four, had for four years been sub-ject to frequent and sudden attacks of uterine pain. She hadborne three children. The last labour was severe, and wasfollowed ever afterwards by sparing and uncertain menstruà-tion.

In December, 1849, when this lady first consulted me, shehad for some months been subject to sudden and alarminglosses of blood, which not only occasioned great sinking at eachtime they occurred, but were rapidly undermining the healthand strength, as evidenced by anasmic pulse, pale lips, ana-

sarca, and extreme nervousness and debility.Examination with the speculum showed a voluminous condi-

tion of the cervix uteri, and a small purplish smooth body (thesize, shape and colout of a large bloom raisin) projecting fromthe os. The surface of this tumour rapidly poured out brightred blood on the slightest touch. This easily accounted fbrthe hsemorrhage. The blood collected and coagulated in thevagina, and was then expelled on any slight exertion. Nitrateof silver applied weekly, in substance, for some time preventedany further serious haemorrhage, notwithstanding the rapid in-crease and protrusion of the growth.

. * See THE LANCET for October 20th, 1855.