: matory fever, with general uneasiness, presently amounting to a state of extreme irritability pain, occasionally of great severity and tearing character, in the præcordial and abdominal regions, along the course of the spine (a sign of importance, inasmuch as those forms of pleurisy and pericarditis which usually complicate aortitis are rarely indicated by continual pain): there is now a tendency to syncope, alternating with restlessness, great heat of skin, a furred and vividly red condition of the lips and edges of the tongue, unquenchable thirst, and a rather full and rapid pulse, with tumultuous action of the heart, imparting a sensation of fremissement to the hand applied over the præcordia. After a time, these symptoms are succeeded by the signs of collapse: there is now extreme prostration; the features either shrink and become sharpened, or are bloated and livid; the surface is cold and discoloured; the pulse rapid and indistinct; the breathing difficult, to orthopnoea, or it may become stertorous; the patient falling into a state of coma, from the occurrence of effusion into the base and cavities of the brain: the extremities swell, their superficial veins shewing, through the skin, in dusky lines of ecchymosed appearance; the respiration is at length performed only by sudden gasps at long intervals; and the patient dies with the general aspect of a person suffering from the absorption of an animal poison. Such are the symptoms which mark the typical form of the disease; but, in the majority of cases, very few of them are present. Thus, a patient sinking from the effects of erysipelas, of extensive suppuration, of phthisis, or, again, from the irritation induced by a surgical operation, may be the subject of extensive aortic inflammation, and still have few symptoms superadded to his condition of prostration and general constitutional disturbance beyond some dyspnoa, together with an increased degree of irritability and distress: so entirely ataxic are some of the forms of acute disease, to which the aorta is liable. Dr. Bright, however, mentions an important sign, which he noticed in three cases of aortitis; namely, the existence of a state of morbid sensibility so intense over all parts of the body, that merely pressing the wrist of one of the patients caused him to cry out with pain." But the disease may escape observation in the last stages of a typhoid fever, or in common with mere thoracic inflammation, or in those who have sunk under low forms of the exanthemata. So that our readers may well suppose that aortitis is more often recognized on the dead than on the living body. Treatment. The admission, on the part of Dr. Chevers, that the disease is a desperate one, is also an admission of the usual futility of treatment. Indeed we may safely venture to say that the disease is as difficult of treatment as of diagnosis. Dr. C. thinks that the occurrence of aortitis, and its concomitant inflammations, might frequently be obviated, by constant attention to the state of the secretions of those who appear to be liable to these attacks, at the same time allowing a proper and nourishing diet, with the temperate use of stimulants where they have long been taken habitually. And it is probable, that surgical patients, in great metropolitan hospitals, would generally escape these attacks, if, before being submitted to operations for the removal of chronic local disease, they were kept for a few weeks upon a moderately-strengthening diet; and were it to become an established rule with surgeons, to defer, if possible, the performance of any operation upon individuals, suffering either from hepatic disorder, or from those states of renal disease which are indicated by albuminous urine, until these conditions were removed, or mitigated, by the usual medical treatment. Dr. C. conceives that, in the commencement of aortitis, the milder preparations of mercury may be given in small proportions, combined with large doses of opium or hyoscyamus, providing the patient remains perfectly free from symptoms of cerebral mischief. Again: Where there is evidence of great excitement of the circulation, remedies tending more immediately to tranquillize the heart's action, as digitalis or the acetate of lead, may be employed in combination with opiates. These means will be aided by the application of counter-irritation to the chest and back; but not to a degree sufficient, either to produce severe lesion of the integuments, or to add to the general irritation in the system. The infriction of tartarised antimonial ointments, as recommended by Dr. Copland, together with drycupping, are not contra-indicated; whereas the use of blisters, issues, and setons, is highly objectionable, on account of the feeble power which the constitution possesses, during the continuance of the disease, to repair structural lesions, even of the slightest kind. In the latter stages of aortitis, the frequent administration of small quantities of the stimulants to which the patient has formerly been habituated, or of ammonia and other agents calculated to fulfil the same intention, with the application of warm and stimulating liniments to the chest, will nearly comprise the therapeutics of this disease. Such are the views of Dr. Chevers. With the utmost deference to observation so careful, and precision so great, we still feel incredulous of the amount of aortitis reputed to exist by Dr Chevers, and not quite satisfied with the nature or amount of the evidence adduced. Probably we are wrong, but we cannot help suspecting that much of what goes for aortitis is the consequence of imbibition in the later hours of life, or after death. V. CASES OF MALIGNANT DISEASE OF THE LUNG. By Dr. Hughes remarks that, notwithstanding the greatly increased attention which has been latterly paid to the investigation of thoracic complaints, and the exactness with which, by the aid of percussion and auscultation, the existence of many affections may be predicted, the diagnosis of malignant disease of the lung remains in a great measure uncertain. The absence of any definite symptoms, and the indeterminate character of the physical signs-or the limited opportunities of ascertaining them, in consequence of the comparative rarity of the complaint, have hitherto rendered its detection a matter of difficulty and of doubt. It may indeed still be said, in the words of a recent writer, "As yet, almost nothing has been done, in establishing the diagnosis of this disease." 66 Dr. Stokes has mentioned two forms of the complaint. In one, degeneration of the lung occurs, and the organ is transformed into a cancerous mass. In the other, a tumor is formed external to the lung which it ultimately displaces as it progressively increases in size. He has not noticed, or only slightly alluded to, a third, and, according to my own observation, a very much more common form than either of those to which he has referred. In these cases, rounded masses, varying in size from small marbles to small oranges, white, pink, or purplish, in colour-and solid and semitransparent, or friable and opaque, according to the age or character of the affection-are found distributed throughout the greater part of one, or, more commonly, of both lungs; while disease of a similar kind, but in a more advanced stage, exists in some other organ or organs of the body, as the mamma, uterus, testicle, kidney, or liver, or in the bones and soft parts of the extremities. When, indeed, fungoid disease has long existed in any part, and at the period of the patient's death has already made considerable progress, it is far from uncommon to find, on dissection, masses of the character alluded to in the lungs, as well as in other internal organs. Dr. Hughes introduces four cases. The first of these is a Case of Fungoid Disease of the upper part of the Lung.-Mary Benbow, aged 50, a washerwoman, admitted August 19, 1841. Two years ago, she caught cold, and was confined to her bed for two months; ever since which she had been subject to occasional attacks of hæmoptysis. She had been under Mr. Kingsford's care for nine months; and during that time had been several times attacked with spitting of blood, for which, on two occasions, she was bled; but was generally treated by the administration of acids, acetate of lead, digitalis, and saline purgatives. When admitted into the hospital, the countenance was rather pale and sallow, with a few enlarged cuticular veins in the cheeks; her legs were swollen; she had no pain, nor was she particularly emaciated; she lay upon her back, with the shoulders rather raised, and somewhat inclined to the right, but could turn to either side, or get up without much inconvenience; she complained of cough, accompanied with shortness of breath and sanguineous expectoration; her tongue was slightly coated, and moist; her skin soft and unctuous; her pulse frequent and feeble; her bowels regular. The sputa, on examination were found to consist of white frothy mucus, with some portions of a light crimson colour from their perfect admixture with brightred blood. She had one absorbent gland, nearly as large as a pigeon's egg, in the right axilla, and a smaller one under the right clavicle; but had not been aware of their existence till they were pointed out to her. The superficial cutaneous pain of the right side of the abdomen, and the lower part of the chest, were considerably increased in size, and rather tortuous. Physical Signs.-On inspection of the chest, it was at once evident that there existed a very decided sinking and flattening below the right clavicle, extending nearly to the mamma; that the ribs of the part were very little moved in respiration, and that when elevated however slightly, they were raised en masse as a solid unyielding case. Over this portion of the chest, at the upper part of the right axillary region and over the right scapula, there existed a perfect deadness of sound on percussion; complete loss of the respiratory murmur; very marked tubular or tracheal respiration, only rarely accompanied by a little coarse mucous rattle great shrillness and loudness of the voice, approaching to imperfect pectoriloquism and obviously increased tactile vibration. The morbid phenemena appeared to terminate at a defined line just above the mamma, and to pass round the whole of the right side of the chest. The lower portion of the right and the entire left lung appeared healthy. It is unnecessary to enter any notice of the treatment adopted, as only palliatives were employed. Her symptoms varied but little she had occasionally severe pains of the left side, which were relieved by sinapisms; her dyspnœa became gradually worse, and soon amounted to orthopnoea; the oedema of the legs increased. She had no ascites, and, while in the hospital, had no hæmoptysis of any severity. The physical signs remained of the same character, but extended downwards with considerable rapidity. Without any particular suffering, or very great emaciation, she died exhausted, Oct. 17th. Dissection-The left pleura was slightly adherent, from old standing disease. The left lung was crepitant throughout, and partially emphysematous. The right pleura was universally firmly adherent, and superiorly altered in texture by a white flaky malignant deposit. The entire upper part of the right lung was converted into a mass of medullary fungus, the cut surface of which exhibited a dead-white cheesy substance, intersected with bands of cellular tissue. By slight pressure, a creamy fluid exuded, together with portions of soft brainlike matter, from cells varying in size from a pin's head to a marble. The middle lobe contained some portions of the malignant growth, appearing like elongations or processes of the diseased mass above them, from being clearly connected with and traceable into it and separated from each other by the intervention of healthy or simply compressed lung. The interior lobe contained a few small detached masses of fungoid matter, and was, posteriorly, firm, dark-coloured, and lacerable, probably from gravitation. In the branch of the right pulmonary artery, going to the upper lobe, there was a small pedunculated medullary tubercle, and another on its external surface. The heart and pericardium were natural. We third. pass over the second case, although not uninstructive, but pause at the Case of Fungoid Disease of the Thigh and Lungs.-Sarah Swaisland, aged 14, admitted into Guy's Hospital, under the care of Mr. Callaway, Jan. 6th, 1841. About a year ago, she received a kick from a boy upon the knee; and a short time before admission, the joint became swollen and painful. When she entered the hospital, it was inflamed and tender, but not much enlarged. It increased, however, very rapidly in size, and amputation was proposed; but not assented to, till it was impracticable. Her pain was relieved by morphia: but neither topical applications nor internal medicines had any effect in retarding the growth of the tumor. She died June 1st, 1841. Her chest was not examined during life, as she had no constitutional irritation, no cough, difficulty of breathing, or hæmoptysis, to induce her attendants to suppose that she had any disease of the lungs. Dissection. The body was emaciated, and the mammæ but little developed. The great tumor consisted of radiated, long, and fungoid tissue, very, but variously, fleshy and vascular; soft, and but little or nowhere cerebriform; and in little parts, escaped from within the periosteum. The joint was but little inflamed. There was suppuration about the groin; both legs were more or less oedematous : a turbid effusion in the periosteum. The liver was large, coarse, and soft; or so flabby as to give the idea of a sac of fluid. It was not very lacerable, but darkish. The lungs contained numerous tubercles, about the size of peas and chesnuts, firm, roundish, nodular, semicartilaginous, somewhat translucent; and some were very earthy. The heart was small. A case like this, shows, as Dr. Hughes observes, that numerous masses of fun goid or schirrhous matter may be deposited in the lungs, while a similar disease is advancing with greater rapidity in some other part or parts of the body, without causing any symptoms of pulmonary irritation. The attention of the observer is, consequently, not particularly directed to the state of the chest; it is not at all, or only very superficially, examined; and the disease of the lung is often not even suspected, till displayed upon the inspection-table. All who have seen much of cadaveric examinations have seen instances of this sort. We frequently hear of patients dying consumptive who have been operated on for cancer. No doubt, malignant disease of the lung is mistaken frequently for phthisis, and practitioners would do well to peruse these cases and prepare themselves for similar occurrences. After relating another case of dubious character, Dr. Hughes sums up : 6 "I presume the two first cases herein related are genuine and characteristic specimens of what Dr. Stokes calls cancerous degeneration' of the lung. If, then, the two last cases are excluded from consideration, and a review taken of the two first in connexion with the two of a similar form of the disease recorded by that experienced physician, it will be found, that, in all four, the disease existed on the right side-that all were more or less troubled with hæmoptysis-that, in three out of the four cases, the sputa, which in the fourth are merely stated to have been tinged with blood, presented a very peculiar appearance, Dr. Stokes having compared them very curiously to black-currant jelly,' while I have frequently publicly noticed their resemblance to 'red-currant jelly mixed with water that in all there existed evidence of obstruction in the superficial veins of the affected side, evinced either by the enlargement of the vessels themselves, as in three, or by edema of the parts situated, in reference to the progress of the venous current, just below the diseased organ, as in the fourth-and that, in two, tumors were discovered in other parts of the body. It will also be found, in reference to the physical signs, that there was, in all, perfect dulness on percussion; absence of the natural vesicular murmur; and tubercular or tracheal respiration, without any rattles, or with only a little, of a simply bronchial character. We may, perhaps, therefore conclude, though there are no physical No. 87. 21 signs at present known which are peculiar to or are pathognomonic of this complaint, that when there exist signs of extensive solidification of the lung, without either the previous history of pneumonia, or any evidence of softening of the morbid product-when the patient has been troubled with hemoptysis, and the general symptoms and progress of his affection are inconsistent with the presence of tubercles when the sputa occasionally consist of blood, so thoroughly incorporated with serous fluid as to resemble currant-jelly-and when the veins of the neck, arm, chest, or abdomen, on the affected side, are enlarged, or there is local edema proving obstruction to the flow of blood within thema suspicion may be entertained of the existence of malignant disease of the lung; and that this suspicion will be strengthened by the complaint being situated on the right side, and especially by the appearance of tumors in other parts of the body. It must however be added, that the disease sometimes, as in the second case herein related, very accurately resembles empyema-that the history of the case, and the physical signs, are on such occasions insufficient for the purpose of distinguishing the two complaints-and that the diagnosis, if at all practicable, must then be deduced from the general symptoms, the peculiar character of the expectoration, the obstruction to the flow of blood through the superficial veins of the affected side, and the appearance of malignant tumors in other parts." It is our impression, although we should be sorry to speak very positively to the point, that we have seen at least one instance of medullary tubercles in the lungs unattended with the expectoration described by Dr. Hughes. Unfortunately, we have lost our notes of the cases, and can only speak thus loosely from memory. The subject merits close observation. It is pretty clear that when a patient, who has suffered from malignant disease in any organ, complains of thoracic symptoms, suspicion should be pointed to the probable occurrence of malignant affection of the lungs. Dr. Hughes has done well to draw more general attention to the subject. VI. REPORTS Of Cases requiring Capital OpERATIONS WHICH HAVE BEEN PERFORMED SINCE OCTOBER 1, 1840. By BRANSBY B. COOPER, Esq., F.R.S. The following list is subjoined. OPERATIONS IN CASES OF IMPORTANCE, PERFORMED IN GUY'S HOSPITAL, BY MR. B. B. COOPER, FROM OCT. 1840 TO JULY 1841. For Aneurisms 4 in Guy's Hospital: 1 in private practice : Of the Subclavian Popliteal Lithotomy-5; viz. In Children In Adults 1, unsuccessful. 3, all successful. 1, successful, (in private practice.) Excision of Elbow-Joints-2, both successful. Excision of Cartilage from Knee-Joint-1 still doubtful. |