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Birmingham Pathological SocietyAuthor(s): James RussellSource: Provincial Medical Journal and Retrospect of the Medical Sciences, Vol. 4, No. 11 (Jun.18, 1842), pp. 215-217Published by: BMJStable URL: http://www.jstor.org/stable/25491265 .

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PATHOLOGICAL SOCIETY OF BIRMINGHAM. 215

chronic inflammationi of the spinal marrow; I there

fore applied my remnedies to the cervical region of the

spine, and soon cured my patient." Galen then shows

hiow the spinal marrow had been contutsed on a level

vith the seventh cervical vertebra, near the origin of

the ulnar nerve, which is distributed to the two last

finigers anid to one side of the middle finger, and he

affirms that, with the assistance of anatomy, we can

determine accurately not onlly the portion of the spinal

marrow which is affected, but even the particular

nerve. Assuredly, with all the advantages of modern sci

enlce, we have not surpassed, if we have equalled,

this accuracy of diagnosis.

PROVINCIAL MIEDICAL AND SURGICAL ASSOCIATION.

The members and friends of the Provinicial Asso

ciation are informed that the tenth anniversary meet

ing will be held at Exeter on Wednlesday and Thursday,

the 3rd and 4th days of August next, wvhen the attend

ance of all those inlterested in the objects of the society

is requested.

CHARLES HASTINGS, M.D.,

J. P. SHEPPARD, Surgeon,

Secretaries to the Association.

Worcester, June 14, 1842.

BIRAIINGHAM PATHOLOGICAL SOCIETY. Mlay 7, 1842.

JAXMES RuSSELL, Esq., in the Clhair.

INFLAMMATION OF THE LUNG.

Dr. FLETCHER exlhibited to tlle society the coii

tents of the thorax of Henry Underhill, aged 19, wlho had been operated upon for empyema of the left sidc

of the chest, by Mr. George Elkington, ill Jaiitiary,

1839, and had died on tllhe 2tli of April, 1812, from

inflammation of the right lung, after four days' illniess, dating from its very commeencemeint.

In the begiming of Jainuary, 1839, Dr. Fletcher

saw the case, in consultation with Mir. George Elking ton. The patient was suffering froIn all the signs of

effusion to a considerable extent on the left side of the

cliest, which measured about an inclh amld a hallf more

thanl the right, and the heart was much puslhed to the

-ilht side. AMr. G. Elkiig-ton lhad tliell been ill daily

attendanlce upoIn him from the imiglit of November,

1838. He was first seized -with plenritis of the left

side, which afterwards appeared to be complicated w ith pericarditis; dturinig this period lie improved at

fir.st, but on renewing Iiis cold he became mutell worse, aid the effusion came oii. Tlhe propriety of operation

was now to b)0 coiisidered, and, as the difficulty of

respiration wvas Inot imnimiieint, it was thouighlt better to mercuralise aild blister the paticnt umiitil the symnp toins became more uirgenit, or the case improved.

The remedies acte( well, but iii spite, of tlhelmi tile

case became so uirgent, firom the difliemilty of respira tioni, that the openation of paraceintesis thoracis was

determined upon, and performed by Mr. George Elkington, on the 23rd of Januiary, 1839. About fi-ve

pinits of pure pus flowed through the canula, and

I rather more than that quantity before it ceased to

discharge; an abscess then forined in the viciniity of

the punctare, which Mr. G. Elkington opened on the

30th of July, 1839. This continued to discharge a

little for some time, but eventually closed. At the

first period after the operation, the affected side of

the chest became much contracted, sounded dull on

percussion, and no respixation was heard, except some

slight brondhial at the top of the side, but gradually

up to the time of his death the respiratory sounds

increased from above downwards, aiid the sound

became more pulmonary in its character on percus

sion, and the side affected iiiereased in capacity.

He so much improved in every respect, as to be able

to resuLmne his employment of manufacturing cigars;

but was very stubject to inflammatory attacks of the

riglht lung on any exposure to cold, which, as must

be seen, from his having butt that lung in its integrity,

placed him in imminent danger. Dr. Fletcher saw him

in great danger, from this cause, in December, 1839,

also in May, 1840; and at other times, when affected

with more slight attacks, lie required very prompt

treatnieit; and that at all times the organs of diges

tion should perform their functionis normally, and

that the air he breatlhed shouild be good anid free from

dust, to keep him in at all a comfortable state of

existence. Dr. Fletcher saw him in February, suffer

ing much from asthma, in consequeiice of being

employed in brass castinig, which was immediately

relieved onl hlis obtaininlg anl employment in which he

was less exposed to a dusty atmosphere.

On Monday, the 25th of April, Underhill sent for

Dr. Fletcher, with a message that lie wished to see

him, as he was ill a dying state. He had been ill

three days, and had then inflammation of considerable

extenit in the right lung, from which lie died that

eveining.

The post-mortem examiiiatiol wa-as made on the

morninig of tIme 27th, thirty hlours after death.

The body was eimaciated, the left side of the thorax

was contrActed, anld the shoulder of the same side

was low^er tlhain the other. The body very closely

represented the plate, givemi in Laeiimiec, of the coni

tractioIn of omme side after a similar aflection. The

thorax measured over the nipples 27 imiches, the right

side 15, the left 12. The ribs of the left side were

lower than their corresponding oiles oni time right, and

the cartilages were blent upon themselves. The left

lung was very closely aldherenit to the costal pleura in

its whole extent, butt AN-as iiiuch contracted in size ; it

only reached anteriorly to the costal ends of the car

tilages, and downwards to the seventlh rib. The right

lung was adherenit in many places by elongated adlic

sions, anid projected more anteriorly and to the left

side than normal, and seemed in all respects larger

than natural ; large flakes of lymph were throwvn out

uponi its surface and betw een the lobes, unitimig them

together. The heart was adliereit throuighlouit the

wlhole extent of its surface to the pericardium. The

dorsal vertebrT were cuived, lattving their convexity

to the right, and there wvas ilO coiimpenlsating curve in

amiy otlher part of the spine.

The abdominal and pelvic viscera were healthy,

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216 PATHOLOGICAL SOCIETY OF BIRMINGHAM. except that the spleen was bound to the diaphragm

by extensive adhesions, which showed that the peri

toneum, in that situation, had been affected with severe

inflammation. The contents of the thorax removed from the

chest floated on water. The heart was dilated above

half its normal size, which equally extended to all

its cavities. The left lung was about a third its nor

mal size, of a dark colour, and appeared atrophied,

but crepitated on pressure in its whole extent. Its

vessels and bronchi were normal in capacity, but ap

peared shortened; its superior lobe only was seen

anteriorly; its inferior lobe was contracted and

drawn upwards, and appeared to have fitted into

the hollow formed by the superior part of the con

cavity of the curvature of the spine. A slice cut

from it floated on water. The anterior edge of the

right lung was in a state of emphysema, with prominent

air-blebs formed by the coalition of several lobules,

some of them as large as walnuts; they extended all

along the two superior thirds of the anterior border.

Farther outwards, the lobules were more rounded and

bulging than natural from distension, and presented

an unusually brilliant appearance; more outwards, the

lobules were not so decidedly enlarged, but throughout

the whole extent of the lung they appeared dilated

and affected vith vesicular emphysema. Laterally,

and somewhat anteriorly, the lung was inlfiltrated and

in the first stage of inflammation; posteriorly it was

in a state of red hepatisation; the separation between

these two stages of inflammation was very distinctly

marked and abrupt. Portions taken from the differ

ently affected parts of the lung were of very different

specific gravity ; anteriorly it was very light, and

floated lightly on water. A portion taken from the

lateral part of the lung, where it was in the first

stage of inflammation, was not so buoyant, butt still

aoated. That taken from the lhepatised portion

sank in water, like a piece of liver.

EXTENSIVE CANCEROUS DlSEASE.

Dr. BLAKISTON laid before the society specimem,

of cancerous deposit in the liver, glands of the gastro

hepatic omentum, pancreas, bronchial glands, and

lung. The subject from which these morbid speci.

mens were taken was a car-driver, a man of small

stature and spare habit of body, wlho was admitted

into the Birmingham General Hospital, unlder Dr

Blakiston, February 24, 1842.

For six months he had been labouring ulider a

severe and shooting pain, which seemed to radiate

from the epigastrium towards each hypochondriuim,

and vhich at first was intolerable in the recumbent

posture. He had become much emaciated, and hadl

thought that the right hypochondrium had increased

in size. At the time of admission, his countenance

w-as pinched and anxious, expressive of much bodily

suffering; lie was emaciated, and there was anl earthy,

leaden-coloured appearance over the countenance,

especially under the eyes; the puilse was small and

feeble, but not frequent. He experienced great paiin

in the epigastrium, shooting backwards aind towards

each side. Neitlher the organs of respiration or circu

latioii presented any physical signs of disease. His

appetite was moderate, and the bowels acted freely.

The abdomen sounded dull on percussion about twc

iniches below the leyel of the ribs on the riglht side,

and about four inches on the left, where was felt the

hard, abrupt edge of some solid rough body, appa

rently intimately connected with the left side of the

liver, and not raised by pressure upwards from the

left loin. The diagnosis given was malignant di8easc

of the liver.

The hydrochlorate of morphia was administered,

and was followed by some mitigation of pain. Towads

the end of March the right hypochondrium had be

come perceptibly larger. Dr. Blakiston thought he

felt a round hard tumour deeply seated under the ensi

form cartilage. Disease of the glands of the gastxo

hepatic omentum was added to the diagnosis. The

pain being now severe, a blister was applied to the

epigastrium, and morphia was sprinkled on the vesi

cated surface without relief. The dose of morphia

given internally was then increased with benefit.

Ascites and edema of the feet soon came on, and the

conjunctiva became slightly tinged with yellow; he

gradually became more feeble and emaciated, and

was afflicted with dryness of the mouth, some dimness

of vision, and severe pain and giddiness in the head;

he began to feel a pulsation under the ensiform carti

lage like the ticking of a clock. He died, worn out,

May 3, 1842.

Autopsy.-The heart was small, but presented no

unnatural appearance, except a slight thickening of

the free edges of the tricuspid and mitral valves, all

of which, however, acted perfectly.

The left lung, at its lower and outward portion,

adhered closely to the ribs over a space of the

size of a half-crown piece. Here it had a dark

puckered appearance ; when cut into, a cavity was

found which might have containied a walnut, present

ing a dark appearance, but containing no fluid, and

having no lining membrane; at its inner side was a

mass of cancerous deposit nearly as large as a date,

the part of which nearest the cavity resembled it in

consistence, gradually becoming hard and white as it

receded from the cavity. A little above this were

two or three small cavities of a similar kind, entirely

empty, anid communicating with the interlobular

fissure by smooth rounded apertures, into which the

pleura of the fissure seemed drawn for a very short

distance. One of the bronchial glands was about

the size of a large date, and contained a mixture of

its own material, aiid of hard, white, and yellow

caseous-lookineg miasses.

In thlc abdomenz were scevral piits of clear yellow

serunm.

The liver projected muclh below the ribs, and was

hard to the touch; its convex surface was studded

with canlcerouis tubera, from the smallest size nearly

to that of anl eg. Tlhey wcre all depressed at the

centre, w,ere whitc, w%vitlh fringes of blood-vessels

arounid their circumf'erence. Onl beinig cut into they

were of scirrhous hardness, except the largest, which

was slightly softened in its centre, and there exuded

from their cut surfaces a thick yellowish slime. The

substanlce of the liver was yellow.

The glands of the gastro-hlepatic omentum were

coniverted into similar masses, anid were glued to the

pancreas, a portion of which, particularly one tip or

edge, was in a scirrlhonis state.

Dr. BLAKISTOIN remarked, tllat, in tlle opinion of

some, the cetltral depressioln obseryed ini cancerous

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ACADEMIY OF SCIENCES, PARIS. 217

tubera, like those wlicil he laid before the society, indicated their slow developmenit. In this case they had probably existed ait least for many months; it was, lhowever, worthy of notice, that the smallest tuber had this depression equally well marked with the largest.

It was extraordinary that not a tracc of the canl cerous matter in a fluid state could be found in the cavities in. the left lung, where it inust havc existed, and whein il one case the process of absorption seemed actually to lhave been going oIn at the timne of death. The state of this lung was not such as to afford any marked pllysical signs of disease, the extelnt of lung diseased being very small, and the cavities contailling no fluid which could give rise to miioist rattles. The crude mass cotuld not be inldicated by duliiess on per cussion, as it was separated from the parietes of the chest by a cavity formed by the absorptioil of a portion of it. So also the bronchial gland had not reaclled such a size as to give rise to any l)hivsical sig,ns of its diseased state. In a case, howvcver, wlhich he had

mentionied to the society some time back, the supe rior vena cava had becen embraced by the bronchial gland w-hich had becn invaded by this disease, anld edemiia of tlle head, neck, and armns supervened.

The malignant disease of tlle liv-er had been recog nised by the touch on the left side. The rough tumour felt in the left hypochonldrium could n(ot be an en largened spleeni, as it did niot follow the oblique direction lwhich suclh tumours usually do; anid niot beinig affected by upward pressuire from the region of the kidney, it could nlot be considered to be conl nected with that orgain. It seemced traceable under the ribs onl that side upwards, and downwards it pre sented a lhard, slharp, well-defiined cdge. The ritTht lobe was proportionably enlargenled, and, tlherefore, descended mnuclh lower tlhan the left lobe; but about tw-o inelhes below the low-cr miiargin of the thorax it dipped dowvi inlto the abdomen at a considerable angle, anld thereby allowed the inltestiices to imiterpose themselves between its lowver hallf and the abdomiiinal

parietes, so that it could niot be I'(lt. The cancerous nature ot the disease was inferred both from the rouglhness of tlle abdomliinal tuinour and the genieral appearanlce of the patienit. The violent slhooting pain he suffered formed nio elemnenlt of the diabuosis, as Andral aind others hiad sliowvn by ex-perience that it was of 0lo value as a diagnostic sign in suclh cases. It was the opiniioIn of some that the absenice or presence of paiil depeended on the dhegree ini wvhich the perito nieal coverinlg of the liver was imivolved; in otlher words, whether the tutbera were superficial or deeply seated in the parencli ma of the organ. It was well known, however, tlat clironiic peritomiitis was seldom attenided with paini of this kind. Dr. Blakiston,

moreover, stated tlhat, in comIjuIictioii with Dr. Hucy, he hiad attended a late eminienit arclhitect w%vho died of cerebral affectio,l. lie hlad hald intestinial h&.rmorrhage, but had experienced iio paili of anyv severity in the abdomeni, aid yet the comivex surface of both lobes of the liver w as thicklY studded with canicerous tubera, some of wlvicli were of larg-e size, aiiid projected far above it.

Dr. BLAKISTON- felt di.Uposed to attribute the pain in the epigastric region in this-tl case to tlhe coniipres sioim of the nerves in tlh.at locality, whiich1 were in1

volved in the mass of cancerous disease wlhich was

situated in the gland of the gastro-hepatic omentiim,

and in the pancreas. Of these the nervusvagus, at least,

was probably more senisitive than those whiclh had al

ready reached and were distributed in parenchymatous

organs. He mentioned the case of a man at Cain

bridge, who sulffered simlilar paini, anld in whom the

only disease that could be discovcred was situated in

these glanids, which were filled with round calcaieous

masses, which, though conistituting a different disease,

w%ould affect the nerves in the same physical mainner

as in this case.

Ile was led to diagposticate the disease of these

glanids partly from the nature of this pain, and partly

by toucl ; but hc did niot conisider that either or both

of these signs formed a sufficient basis for an accurate

diagnosis. This view of the case was confirmed,

hlowever, at a later period of the illness, by the tick

ilng sen1sationi in the epigastrium, wllich was, doubt

less, cauised by the propagation of the pulsations of tlle

abdominal aorta to the walls of the abdomene by the

mass of diseased glanids, and which was felt by the

hand. The affectioii of the pancreas afforded no

physical sign of its existence apart from that fur

nished by the diseased glanid over it; nor did Dr.

Blakiston knowv of any genleral signls whichl could be

relied on as furnishlinlg evidence of such ain affectioi.

The diagnosis had becl so far valuable, that it lhad

prevented the patient being subjected to uinnecessary

torture in the hope of cure, and had limited the efforts

of his medical attenldants to tlle mitigation of hlis suf

ferings. Dr. MELSON said, at the close of Dr. Blakiston's

observations, that John Aston had formerly beein an

out-patient of the Queen's Hospital, suffering from a

severe attack of general rheumatism, with extension

of the disease to the inner membrane of the lheart,

indicated by a well-marked and persistent bruit de

souiffle. Thc souffle yielded to the iodide of potas

siumn treatment, but thc general rheunmatism assumed

a chronic character. Throu,hout thc whole of Dr.

M.'s protracted attendance upon the patient, he had

suffered most acutely from a pain in the side, corre

sponding in situation accurately with the pulnonary

lesioin niow exhibited. Tllis pain was perfectly in

vinicible, and was the great source of his suffering.

He dated its origin from a severe blow which he had

received from a drunken man whilst following his

ordinary avocation as a carman.

ACADEMlY OF SCIENCES, PARIS.

June 6.

COMlFOSITION OF CONFINED AIR.

Al. Fclix Leblanc read a nmemoir on the composition

of conifined air. The author had analysed, after the

miiethod of Ml. Dumas, the air collected from various

localities, as the wards of hospitals, the theatre,

chamber of deputies, &c. Fiiially, hc analysed atmo

spheres rendered poisonous, either by pure carbouic

acid, or tllc products of combustion. At the time of

taking the air, every circumstance of any imiiportance

was noted, sIclh as the temperature, ventilatioil, &c.

Air- in HIot-kouses.-In air collected during the

eveninig, the relativ-c proportioins of oxygen and nitro

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