in this case, and from his previous experience, Zimmermann considers as the most important changes in the inflammatory blood-that it is less coagulable than the blood in health; that the quantity of fibrine is augmented; that the coloured blood-globules are diminished in number, and possess an abnormal disposition for the formation of rolls; that the colourless globules are found in an increased proportion, and show, likewise, a tendency to join in groups.-Prager Viertiljahrschrift, 1852, vol. iv. p. 97.

Decennium Pathologicum: Contributions to the Pathology of Chronic Disease. By THOMAS K. CHAMBERS, M.D.

THESE eight papers are the beginning of a series, designed to test, by statistics, the accuracy of our generally received opinions concerning the effects of disease. The author has, as yet, not got beyond "Tuberculosis." The groundwork is the record of about 2500 fatal cases, of all kinds, preserved in the post-mortem books at St. George's Hospital. The first step was the construction of "an index, in which each morbid appearance observed is alphabetically enumerated, with a reference to the volume and page where it is found:" on the plan, we presume, of Giambattista Morgagni's Index visorum in Cadaveribus, in the Venice edition of the Epistole de causis et sedibus morborum. Then instances of various lesions were arranged in tables, under the head of the various viscera affected or the nature of the disease, and the index and tables submitted to mutual correction. The tables are not published, but simply a numerical enumeration of various facts which appear in them, of which, of course, only an outline can be here attempted.

The two first papers are devoted to statistics of the general mortality of the hospital, as a mean of comparison with those of particular diseases, in order that facts which appear in the history of the latter may be assigned to their due causes, whether those are the peculiarity of the malady, or of the locality in which it is observed.

The results are 1st. There is an excess of about in the male deaths throughout the country.

100

2nd. This excess is greater in hospitals, and amounts, at St. George's, to t when accidents are excluded on both sides; and to, accidents included.

3rd. This real excess is augmented in the general hospital reports by an excess in surgical male patients.

4th. The causes of the real excess are in a great measure of social, and not of physiological origin.

5th. The excess of accidental deaths is on the male side at all ages, but most in the middle period of life.

6th. The excess of deaths from other causes was, up to 20, slightly on the female side, but much less so than in the ordinary population of England. After 20, it was on the side of the males, and attained its maximum at 35.

In the third paper the prevalence of tuberculosis and the influences upon it of age and sex are discussed. În no less than twenty-five per cent. of the cases examined, tubercle was found. The next important point is the great preponderance of males in those affected. "In every 100 men there were more than 27, and in every 100 women not quite 22, affected with tuberculosis." The variations of this preponderance at different ages are then shown.

The fourth paper examines the seat of tuberculosis, and then the usual position of it in the lungs, when they are diseased. The idea of its preference for one lung over the other is held to be a fallacy dependent on the usual mode of examining living patients. Pneumonia, pneumothorax, and the conversion of tubercle into chalk are then examined. In the fifth and sixth papers, the location of tubercle in other parts besides the pulmonary organs is gone into with considerable length of detail. The prevalence of tubercle in the kidneys, much greater than had been represented by previous pathologists, calls forth remarks on the connexion between those organs and the skin, and the consequent importance of

guarding it from climatic influences equally with the lungs. Tuberculosis of the intestinal canal is shown to be almost entirely confined to the junior periods of life, and attention is therefore drawn to the different precautionary treatment of patients at various ages. This part of the subject is concluded by speculations on a connexion which appears, by their order in the tables, to exist between the liability of a part to tubercle and its degree of venosity; the inference being exactly the reverse of the doctrine professed by Rokitansky. In the seventh paper, the complication of tuberculosis with diseases of the heart is examined. The connexion is shown to be unusual, by a comparison of the frequency of cardiac lesions in tuberculous and non-tuberculous bodies, but still is much more common than observers of living patients only are aware of. In the post-mortem examination at St. George's, lesion of the heart occurred in seven per cent. of cases of pulmonary tubercle. In the eighth paper, the complications of non-tubercular diseases of the brain, such as softening, inflammation, effusion, &c., with pulmonary tuberculosis, are examined in the same manner as heart-disease was in the former one.

The eighth paper inquires into the connexion of tuberculosis and cerebral disease, both in respect of cases where tubercle existed in the brain and where it did not. Omitting the numbers, the conclusions of the observation of the 2161 cases examined at St. George's Hospital in ten years are

1st. That the secondary consequences of tubercle in the brain were the same, whether the tubercle be in the substance or membranes.

2nd. That the symptoms of these secondary consequences were, in the case of inflammatory action, pretty uniform, but otherwise obscure and variable.

3rd. That independent of tubercular deposit, idiopathic inflammatory conditions of the meninges were most common in the tubercular diathesis-nay, almost peculiar to it.

4th. That the same diathesis disposed also to softening of the cerebral substance, probably of an inflammatory character; but that other diseases had nearly as great a tendency to produce softening, whether truly inflammatory or not is unknown. 5th. That serous effusion on the brain was less usual in tuberculous persons than in others.-Medical Times and Gazette, August, December, 1852.

The Respiration in Pressure on the Brain. By Dr. LANDGRAF. DR. LANDGRAF calls attention to the state of the respiration, in cases of cerebral pressure. It is frequently not stertorous and laboured, as described in books, till the agony; but it is interrupted, that is to say, after from six to twelve tranquil easy respirations, a long pause ensues. The author details cases in proof of the existence and diagnostic value of this sign.-Deutsche Klinik, 1852, p. 39.

and

Temporary Albuminuria. By Dr. BEGBIE.

DR. J. W. BEGBIE alludes to the phenomenon of albuminuria in the following diseases:

1. Scarlatina Simplex. He confirms his former statement that about the period of desquamation, albumen can almost always be found; its presence is associated with renal epithelium, but not with casts of tubes.

2. Cholera.

3. Erysipelas. Usually at resolution or during convalescence. Its presence is not constant, nor its quantity great.

The albuminuria in these three cases is called desquamative.

4. Scarlatinal Dropsy.-The albuminuria may, or may not, be temporaryblood exudation-corpuscles, and casts of tubes, accompany it.

The albuminuria in this case is termed inflammatory.

5. Pneumonia, at the period of resolution, in almost all cases.

6. Typhus and Typhus Abdominalis (typhoid).—From a consideration of the period when the albumen is observed in these last-named diseases, Dr. Begbie terms it critical albuminuria.-Monthly Journal, Oct. 1852.

On Albumen in the Urine of Various Diseases.

HELLER asserts that albumen is present in the urine in all kidney-lesions, though sometimes in small quantity, and that it exists in many other diseases, and often in greater amount.

I. Pneumonia and Tuberculosis acuta.-At the commencement of exudation, while yet the chloride in the urine is in undiminished quantity, no albumen can be found. As exudation increases, and as the chloride in the urine diminishes, a very small quantity of albumen appears, and continues for a long time. This appearance is not constant, but is very frequent. The greater the albumen, and the less the chloride in the urine, so much the worse is the prognosis.

2. Pleurisy-Albumen does not appear so frequently, even when the chloride is much diminished. In the period of absorption it sometimes occurs, and is attended with carbonate and hydrothionate of ammonia.

3. Acute Liver-Affections.In chronic or subacute inflammations, where the chloride of the urine is diminished, albumen appears as in pneumonia.

4. Pericarditis and Endocarditis.-In the first case albumen sometimes occurs; in the last, very seldom, even when the chloride is much diminished. 5. Peritonitis.-Albumen is frequently found, and continues sometimes long after the customary amount of chloride has reappeared, and morbus Brightii is then, perhaps, left.

6. Metritis and Eclampsia Puerperalis.-As in peritonitis.

7. Cholera.-More or less albumen.-Archiv. für Pathol. Chem., Bandi. Heft 8.

On Cirrhosis of the Liver. By M. MONNERET.

M. MONNERET, believing that the term cirrhosis has been applied to very different pathological conditions, endeavours in these papers to speak of it with some precision, while relating the cases of the disease which have come under his own observation. He defines cirrhosis as a chronic and apyretic affection of the liver, characterized by more or less impediments to the hepatic portal circulation, which leads to peritoneal effusion, dilatation of the collateral veins, and often to œdema of the extremities, and hæmorrhages from the various mucous surfaces.

The anatomical changes which almost always accompany these symptoms are induration and atrophy of the entire tissue of the gland, or of its vascular portion, with the yellow change of tissue, whether granular or not. The retraction of the hepatic substance gives rise to the diminished size of the organ, and at the same time that the portal veins become less visible, the yellow portion continues to predominate over the other, until it entirely supersedes it. The thickening of Glisson's capsule and the serous layer that lines the liver completes the anatomical character.

M. Monneret's memoir is based upon twenty-four cases, in fourteen of which autopsies were performed, this being the entire number of cases he has been able to meet with during the ten years his attention has been directed to the subject. He has compared these cases with forty others of the various lesions of the organ, as also with fifty cases of disease of the heart, in which the condition of the liver was examined.

He has taken great pains in the measurement of the liver, by means of plessimetry, having accurately measured in this way 100 patients. In a healthy man lying in the horizontal position, the hepatic dullness commences four centimetres (about 1 inch) below the right nipple, and terminates at the edge of the ribs, which forms a tolerably exact natural inferior boundary. At the medium line, it is placed behind the scaphoid cartilage, passing a little towards the upper part of the epigas. trium. Posteriorly and laterally it ceases at the level of the ribs. The following figures indicate the normal distances which separate the upper line of hepatic dullness from the level of the ribs. In thirty-one cases its mean height at the median line was 5.62 centimetres; its minimum 15, and its maximum 95. To the right nipple the mean was 12.64 centimetres, the minimum 7.8,

and the maximum 18. In the axillary region, the mean was 10-57, the minimum 7-3, and the maximum 13. In the scapular region, the mean was 9:11, the maximum 14. In twenty-five cases the hepatic dullness commenced at four centimetres below the nipple. The thoracic vibration, perceptible to the hand, while the patient counts with a loud voice, extends three or four centimetres below the upper limit of hepatic dullness. In cirrhosis the normal limits of hepatic dullness have never been found exceeded. In some cases they are scarcely diminished, while in nine have they been so by more than five centimetres. The meteoric state of the intestines renders exploration sometimes difficult by pressing the liver into the thoracic cavity: but when authors speak of hepatic hypertrophy they confound other lesions with cirrhosis.

The peritoneal effusion is of very slow occurrence, fluctuation long continuing obscure, and the patient often not being aware of tumefaction of the abdomen. The progress of the dropsy is gradual, and there is not observed those alternations of increase and diminution seen in dropsy arising from hepatic congestion, whether connected with disease of the heart or other lesions. The fact of the dropsy becoming established before anasarca of the extremities, has been too much generalized. The integuments of the abdomen becoming infiltrated sooner than can be explained by the abdominal distension is explicable by the obstruction to the venous circulation.

In like manner the dilatation of the veins of the abdominal and thoracic parietes may become considerable before any notable effusion occurs. The most delicate capillaries undergo dilatation, so that their elegant arborescence becomes perfectly visible, and that by no means always when distension is greatest. These facts are explicable by the obstructed state of the portal circulation. In some cases, however, no such dilatation and inosculation of veins is present, ascites existing alone. In this point of view, it is interesting to remark that in five out of ten of Dr. Hillaret's cases of portal phlebitis there was no effusion. It is probable that in some of these, as well as in some of the cases of cirrhosis, the obstruction has only been partial, and hence the absence of some of the usual symptoms.

Not only, however, is the hepatic circulation thus disturbed in cirrhosis, but in all probability the composition of the blood has undergone change, giving rise to the hamorrhages which are of such frequent occurrence. Epistaxis, slight in quantity, is the form that M. Monneret has usually met with; in some cases the stools have been tinged with blood.

We cannot abstract the details of the eleven autopsies M. Monneret furnishes an account of; but may advert to his summary of the most common lesions. 1. The liver is sometimes diminished by a third or one half its size. 2. Its surface presents more or less prominent lobules, separated by whitish furrows, the normal disposition of the hepatic structure being exaggerated. 3. The capsule of Glisson is thickened, whitish or opaque, more close and resisting, and intimately adherent. 4. This capsule is found in a hypertrophied state, in the interior of the parenchyma, as whitish lines, enclosing the hepatic lobules and sometimes yellow granules. 5. The change in the proportion of the two substances of the liver has long been admitted as a characteristic of cirrhosis; but while acknowledging the convenience of the expressions red or vascular, and yellow or bilious portions, and believing the affection is one which obstructs the circulation in the vena porta, Monneret doubts the correctness of these anatomical statements. M. Lereboullet believes in the conversion of the bilious into fatty cells, and Monneret has always found by the microscope that a large quantity of fat incrusted the biliary cells. He believes, however, that this fatty transformation itself is dependent upon the atrophy of some element of the parenchyma. 6. The extreme frequency of perihepatic peritonitis is of importance in the anatomical history of cirrhosis; for it may be asked whether this phlegmasia induces induration of the proper membrane of the liver, the loss of extensibility of which may be the cause of the hepatic retraction. 7. The degree of induration of the liver varies, being in some cases

comparable to scirrhus, and apparently due to the predominance of the cellulofibrous portion. 8. There is great dryness of tissue from paucity of blood. 9. The alteration may occupy an entire lobe or even the entire organ; but it may do this in very different degrees. 10. As a negative character worthy of note, it may be mentioned that there are no lesions of the bile ducts, and the bile is apparently normal. 11. In several cases a new circulation has been found established in the fibro-cellular partitions of the lobules, a brilliant arterial network being distinctly visible. This may be regarded as a supplementary circulation of the hepatic artery, it having been observed in cases in which the vena porta was entirely or partially obstructed.

In respect to the causes of this affection, the habitual excessive use of alcohol is undoubtedly one; but in other cases bad and insufficient diet is alone discoverable. These circumstances explain the frequency of disease of the alimentary canal, which is observed in cirrhosis. The frequency with which inflammatory disease of the liver has preceded this condition is undoubted: but whether the thickened state of the capsule be an extension of this, or one of the lesions accompanying organic atrophy, is doubtful. Inflammation is not essential, as in certain cases it has not prevailed. The congestions of the liver which are so frequently seen in disease of the heart are not, as has been stated, first stages of this affection. Their effect is to lead to dilatation of vessels, while cirrhosis leads to their obliteration. In cirrhosis the yellow secreting tissue, formed of biliary cells, and yellow granules, is not hypertrophied, and only becomes more visible and prominent from the atrophy of the portal and vascular system. In hypertrophy the functional activity gives rise to jaundice, but not to obstruction of the circulation; while in active congestion and phlegmasia, even when slight, characteristic symptoms are present, as increase in size, tenderness, irregular fever, fibrinous blood, and icteric

urine.

For the treatment of so fatal a disease M. Monneret has little to recommend. At least temporary benefit is sometimes derivable from alterative doses of blue pill, combined with Vichy or soda water, and alkaline or sulphureous baths. The diarrhoea and vomiting so obstinate in some of these cases are best treated by large doses of bismuth-Archives Générales, tom. xxix. 385, & xxx. 56.

Ichthyosis Cornea. By H. MULLER.

THE author describes fully a case which, in point of severity, though not in respect of hereditariness, stands near the cases of the family Lambert. The crusts, on section, were found to be composed of a system of concentric rings, made up solely of epidermic-cells; between the rings, epidermis was irregularly arranged. The whole structure resembled Gustav. Simon's representation of a section of a wart, but the rings were not joined by the cuticle sheathing the papilla, and the masses lying between the rings by the cuticle formed by the parts between the papillæ, as in the case of warts, but each ring-system corresponded to a hair-bulb or to the duct of a sebaceous gland; spiral ducts of sebaceous glands pierced the mass. Ichthyosis, however, may be of various kinds, and especially in elephantiasis the papillæ are chiefly engaged, are long, and hardened and sheathed with abundant cuticle. The author proceeds to make some general remarks on ichthyosis and abnormal cuticular development, from which it is to be inferred that he believes ichthyosis may have, so to speak, various points of departure, and may be connected with hypertrophied papilla, with altered hair-bulbs or sebaceous follicles, or even with degenerated sweat-glands.-Wurzburg Gesell. Verhand., Band iii. Heft 1,

p. 40.

Leucocythemia. By Dr. HEWSON.

CHARLES ROBINSON, aged 17; never had ague, but had been in miasmatic districts; came under the care of the author; he was anemic, and had oedema of the lower